If you live in the United States, and probably anywhere else in the world, you know that America has a healthcare problem. People may disagree about whether that problem is the result of government, big business, or those people who keep getting sick, but almost all of them agree a problem exists.
Most people also think there’s a quick and easy way to fix it, if the government would just get to work on it/get out of the way. doesn’t share this belief. As a former geneticist turned writer, he thinks that the only way to solve the financial consequences of our broken healthcare system is if we see breakthroughs in biotechnology.
I word of warning: he’s less than optimistic.
I’d like to thank you for talking with me, John.
You started off your career as a molecular immunologist, but you’ve gone on to become a full time writer about biotechnology in general. One of the latest things you’ve talked about is how biotechnology could help solve our economic crisis, and that we could be in serious trouble if it doesn’t.
Can I ask what inspired your career transformation?
A number of factors. Mainly my decision was based on the fact that I had been an academic for many years, and I was bored with what I was doing. I wanted to continue a career, but do something different (not completely, but different). I’d been writing as a sideline for a number of years for various biotech papers, so I was essentially expanding and changing my focus. The papers that I write for seemed to like my style, so I took on more and more assignments.
Another point- I’ve always loved science, but I felt that I knew more and more about a more and more restricted area as years went by.
Finally, I’ve always followed and been active in politics (I helped my wife run unsuccessfully for the KY Senate in 2010) and I’m greatly disturbed by the direction in which politics is moving in our country. As I will attempt to demonstrate, I think science is a way out of the present impasse, and may be the only viable solution to the problems that our society faces.
This is something that Dr. Robert Piccioni mentioned in my interview with him about a month ago. Scientists are trained to know “absolutely everything about almost nothing.” I suspect you aren’t the only one who feels restricted as a result.
I don’t know Piccioni personally, but I am great admirer of his many activities.
Your warnings about the future of the economy are pretty alarming, but before we talk about those I’d like to ask something else.
Biotechnology and the economy seem like two very different subjects. Do you feel like you can draw parallels between the two disciplines, or does your understanding of the economy come from a different perspective?
The two are so completely different, that I believe they have to be approached from totally dissimilar angles. The beauty of the physical and biological sciences is that we collect data and if the data is solid, then we form hypotheses; the rules of the game are very clear and everyone understands them. So we move forward, we throw out bad models and accept good ones.
When we get into the social sciences, economics and political sciences, things get murkier, because people have an emotional stake in the outcome that usually doesn’t exist in the physical sciences. They refuse to accept the data, they cherry pick, they try to avoid quantitative arguments.
So I believe in the physical sciences it is much easier to convince an opponent of the correctness of your argument, simply by laying out the facts in a convincing manner.
As the Godfather says, “Nothing personal, just business.”
In political theory and economics it’s completely different, although more for the public than for academs who are more willing to play by the rules.
Are there any obstacles we’ll need to overcome in order for these advances to solve the healthcare crisis, or do you believe that this will happen on its own as long as we keep researching these technologies?
I hope that these changes will come about on their own, as I have little faith in our current political system to advance their implementation.
It never ceases to amaze me just how little faith people have in our political process, regardless of their political leanings. I can’t say I disagree. What are some of the political obstacles we’re facing?
I’m afraid the greatest obstacle is what Al Gore has called, “The Assault on Reason,” that is, the reliance of the public on television for their information on voting choices. Gore believes that this results in huge amounts of money being poured into sound-bite political commercials that are specious and dishonest, and a lack of any serious analysis in actual news reporting. I feel this lack of news content makes it possible for politicians to get elected who despise government, and harbor every intention of eliminating virtually every function that a government must provide.
There is another feature of our government that is unique to our country and this is the system of checks and balances that make it possible for politicians not acting in good faith to bring the government to a halt.
Bear in mind that the Italian government, which has been the butt of American political satire for the last 60 years, just put into effect, in a matter of days, a program of budget cut and tax increases that we have been fighting over for years, with no sign of a breakthrough.
That’s pretty revealing, and strong evidence that these political problems aren’t universal.
Let’s hear some specific examples of how medical technology could help our economy. Some people might assume that the introduction of new technology will simply increase costs, because it will cost money to buy the technology. They might even argue that keeping people alive longer will just hurt the economy. What’s an example of how it could reduce costs?
One concrete example of which I am aware is the use of the monoclonal antibody Remicade to treat inflammatory bowel disease and Crohn’s disease. A colleague of mine who is a gastroenterologist told me that he treated such patients with Remicade and achieved remission in numerous cases (I don’t know the exact track record.) I asked him if the insurance companies would pay for the $10-12 thousand a year cost of the treatment, and he said, sure, because the alternative in these cases (very severe, failed all other treatment strategies) is a $100-200 thousand tab for surgery.
Anytime surgery can be avoided this is a plus for the patient.
On the other hand, let me offer a biotech cost nightmare. Around 1984 the gene for Factor VIII (the antihemophilic protein) was cloned. At the time hemophilia was treated with Factor VIII purified from outdated blood (remember the scandal in the early 80s when many hemophiliacs were infected with HIV) and the annual cost was $10K.
Nowadays hemophilics are treated with recombinant Factor VIII produced in bacteria. The annual cost is $100K. Other genetic disorders are being successfully treated with biotech remedies. Costs run $100K-$500K. There are a lot of genetic disorders that can be successfully treated with recombinant proteins, and it is not clear how our health care system can absorb these costs.
So obviously there are two sides to this, and biotech can either increase or decrease costs, regardless of its potential to reduce human suffering. One thing that you’ve mentioned to me before this interview was the escalating problem of diabetes. You told me that if there aren’t any new treatments for diabetes, and the health trends continue the way that they are, we can expect to spend $36 billion annually in 2050.
That’s in 2006 dollars, and it’s only the cost of dialysis for diabetes patients, not taking into account several other costs. And it’s in comparison with about $12 billion right now. So let’s talk about how biotech could help resolve this problem.
Yes. This is a very difficult problem, since diabetes is two separate recalcitrant diseases, that over the years have not responded well to treatments, But we don’t necessarily need to come up with two different viable therapies. There are many drugs on the market or in development that may offer some benefit, but do not constitute a cure.
They are very expensive and they target one or the other form of the disease. So they represent business as usual.
One of the most, perhaps THE most promising avenues these days is stem cell therapy.
While much of the public interest has focused on embryonic stem cells, there is a less controversial alternative, “induced pluripotent stem cells”, which can be derived from the host and would avoid much of the problems of immunological rejection faced by the introduction of foreign tissue into the body. Tissue rejection appears to be part of the reason that trials with humans patients have so far met with limited success.
Another problem that researchers are grappling with is the fact that the beta cells, or insulin producing cells, are located in the islets: groups of cells that constitute a micro organ in the pancreas. It has been known for 40 years that type 2 diabetes is the consequence of dysfunction of the islet as a microorgan, with insufficient insulin and excessive glucagon (another pancreatic hormone) acting together to drive hyperglycemia.
So this means that a ‘breakthrough” technology to eliminate diabetes in the same way that polio was eliminated in a stroke will require that several really finicky, difficult procedures to come together: a really tall order. We need the cells to respond correctly to the inducing factors; we need to overcome any immunological barriers (without trashing the immune system); we need to pull the various cell types together to make an islet that will function like a natural islet.
Then, assuming the research moves rapidly and successfully to a positive conclusion, we have to factor in the time for clinical trials and regulatory approval. This phase might move more rapidly than a gloomy forecast would have us believe, but under the best of circumstances I cannot imagine a scenario in which we see a breakthrough treatment for diabetes in less than a decade.
The idea that technology will save us from our woes has a bit of a nostalgic feel to it, doesn’t it? It seems almost retro-futuristic.
Many technological advances have occurred in the past, but they don’t seem to have solved our fundamental problems. How would you respond to this position?
The notion that we could improve our lives through scientific advances has the sound of a 1960s world’s fair or exposition, something like the Jetsons. In the decades following the 1960s, extraordinary scientific discoveries in basic life sciences were followed by, well, not so much.
Halcyon predictions that science would cure all diseases failed to materialize. All through the latter half of the 20th century life expectancy increased slowly, but there were no major breakthroughs that eliminated cancer, cardiovascular disease, Alzheimer’s disease, or diabetes.
Nonetheless, incremental improvements continued year to year. For instance, the five year relative survival rate for all cancers diagnosed between
1999 and 2006 is 68%, up from 50% in 1975-1977 (American Cancer Society data).
This is very good news, especially encouraging given that it does not include the developments in cancer research of the last 4 years, since their effects will require a number of years to express themselves and to be measured. The bad news, as always, is the glacial pace of such improvements.
The oncogene was first described around 1975 as a stretch of DNA that mammals in many cases shared with viruses, and which could be altered or mutated so as to cause unrestricted or malignant growth of a tissue. After
30 years, we are finally seeing the approval of drugs based on our understanding of the oncogene. These include Herceptin, a drug that targets the HER2/neu oncogenic protein so that the growth of breast cancer cells that display the oncogene product is slowed down.
Herceptin is a monoclonal antibody and we should note that the first drugs based on this concept appeared in the 1990s, 20 years after monoclonal antibodies were discovered.
So I’m arguing that science can solve these issue that bedevil us, but the public has been deceived into thinking that these changes are going to happen overnight through “breakthroughs”. The press and the scientific community and the “disease establishment” have pushed this misunderstanding over the years so that every time a test tube is raised in the laboratory of a prominent scientist, it is hailed as a “breakthrough cure” for some disease, followed by a barrage of requests for more money for universities, foundations, and agencies attached to various diseases.
This becomes such a mantra that we in the scientific community start to believe it ourselves.
Then it turns out not to be a “cure” and the public becomes disenchanted because of the uberhype for a discovery that may be years away from commercialization, if ever.
So does this mean that I’ve argued myself into a corner, taking diabetes as an example, and then pointing out all the reasons why we’re not going to see a radical change in the treatment of this disease any time soon?
Perhaps, but let me suggest a scenario that is at least imaginable within the near future.
As I point out, the reason many very smart people are highly skeptical over the possibility of any big changes in medicine within the near future is because years have gone by since the 1950s and we keep predicting it, and it doesn’t happen.
But what if we really are, at last, on the cusp of a radical remaking of medical technology? For the last 40 years, life scientists have been floundering around, making every mistake possible, and major cures have gone nowhere. But the number of possible mistakes one can make is finite.
What if these are behind us and our 2011 understanding of science is way, way more sophisticated than it was 40 years ago (ca. 1971)?
I can envision that within the next decade cures so revolutionary will become available for HIV, cancer, diabetes, autoimmune diseases, genetic disorders, and cardiovascular insult, that the public will demand them, and force the government to provide them at a fair and reasonable cost. If these cures were such game changers, then the halfway treatments of pharma companies would become obsolete. For example, who wants a drug that will increase insulin output 10% in diabetics when you could have stem cell transplants and never have to struggle with diabetes for the rest of your life?
So will this happen? I would put the probability of a favorable outcome at about 1 in 5. I hope it will occur, but I’m not optimistic. And if my hopeful vision doesn’t occur, what will be the consequences?
I predict there will be no rational consensus on treatment; the public will demand everything, and refuse to pay for it. Politicians will refuse to discuss in a thoughtful manner the alternatives. There will be no intelligent, thoughtful discussion between the government, the healthcare industry, and the public of the end of life and how to mitigate the pain of this event.
Politicians who do attempt to carry on a rational discussion will be voted out of office. Pharma companies, hospitals, insurance providers, physicians, and the whole healthcare industry will continue to achieve double digit return on investment. They will use all their resources to ensure that candidates favorable to their point of view are elected. Useless, super high-tech medical care will be the order of the day, spending hundreds of thousands of dollars on patients in their last few months of life.
I hope my most pessimistic view of the future will not occur, and I would welcome any attempt to dissuade me of this view.