February 07, 2005
US Federal Medical Research Budget To Lag Behind Inflation
The Bush Administration proposes to not allow biomedical research funding to keep up with inflation and therefore is effectively proposing cuts in biomedical research funding.
Under the president's request, the budget of the National Institutes of Health, which doubled from 1998 to 2003, would rise by 0.7 percent, to $28.7 billion next year. That is much less than what would be needed to keep pace with the costs of biomedical research, which are rising more than 3.5 percent a year.
For the National Science Foundation, Mr. Bush will request $5.6 billion in 2006, an increase of 2.4 percent, budget documents show. Mr. Bush requested an increase last year as well, but Congress ended up making a small cut in the agency's budget for this year.
At the Food and Drug Administration, buffeted in recent months by concerns about drug safety, the budget would increase by 4.5 percent, to $1.9 billion.
Aside on the FDA budget increase: What we need are more drugs in the drug pipeline, not more regulation of the drug development process.
The Bush Administration announced almost a year ago that funding of most categories of research was not going to keep up with inflation. The latest announced NIH budget increase for FY 2006 is even smaller than the 2% increase for fiscal year 2005.
The US federal budget is running a large deficit. Cuts have to be made. But medical research is a penny-wise pound-foolish place to cut spending. What we need are better treatments that are more cost-effective. Advances in medical science and in supporting technologies will some day yield treatments that are both much cheaper and much more effective. During transition phases early and less effective treatments cost more than not being able to do anything at all to treat a disease. But more advanced treatments that attack problems at the root level will inevitably cost less.
If we delay efforts to find cheaper and more effective ways to treat diseases then the avoidable cost in the long run of using less effective and more expensive treatments is going to dwarf the sums saved by cuts in medical research.
Stanley Kurtz lays out a gloomy future due to medical spending increases for an aging population.
The Congressional Budget Office estimates that the combined cost of Medicare and Medicaid alone will consume a larger share of the nation’s income in 2050 than the entire federal budget does today. By 2050, the combined cost of Social Security, Medicare, Medicaid, and interest on the national debt will rise to 47 percent of gross domestic product — more than double the level of expected federal revenues at the time. Without reform, all federal spending would eventually go to seniors. Obviously, the system will correct before we reach that point. But how?
The industrialized countries with aging populations are faced with a future of much higher taxes and benefits cuts as well. The unfunded liabilities for the care of old people are literally orders of magnitude larger than the amount spent on medical research. Take that $28.7 billion dollar figure cited above for the NIH research budget. Sound like a large number? The new Bush Administration proposal for the fiscal year 2006 budget is $2.57 trillion dollars for an economy that will be somewhere in the neighborhood of approximately $12.5 trillion per year based on an increase from the fourth quarter of 2004.
Current-dollar GDP -- the market value of the nation's output of goods and services -- increased 5.3 percent, or $152.1 billion, in the fourth quarter to a level of $11,967.0 billion. In the third quarter, current-dollar GDP increased 5.5 percent, or $157.4 billion.
But, barring cuts in entitlements, in 2050 Medicare and Medicaid alone may cost proportionately more than all of the US federal government today. So their costs alone could become be about 2 orders of magnitude more than is currently spent by the US federal government on medical research.
Of course government spending is only one portion of total medical spending. So even if medical entitlements programs are scaled back the portion of total GDP that goes to medical costs could be much higher than it is today.
While projections from current trends yield a bleak financial situation in 2050 it seems reasonable to assume that medical science is going to advance greatly by 2050. Even without higher levels of funding for medical research the rates of advance of biotechnology and biomedical science are likely to produce effective and cheap treatments by 2050. Some of those advances will produce cheaper treatments. Therefore I am less concerned about financial crises brought on by aging populations in the Western industrialized countries in 2050 than I am in the medium term, say 2025. We need to make medical advances come sooner so that we can cut costs, reduce the incidence of degenerative diseases, and increase the number of years people can work before Western countries get caught up in economic stagnation caused by higher taxes.
Here is another financial way to state my basic argument: Western governments have committed themselves to provide enormous quantities of medical care in the coming decades that those governments can not afford to deliver. The political debate on how to handle these commitments tends to center around whether to raise taxes, cut benefits, impose price controls, or inject more market forces into medical care. All four of those responses have either substantial downsides or insufficient upsides or both. Some of the approaches will even make the problem worse while also producing lower living standards. Let us consider each potential response in turn.
First off, taxes can be increased. But taxes raised beyond some point cease to produce a net revenue gain because people will respond to high tax rates by working less. This will slow economic growth and therefore in the long run will reduce the size of the underlying economy available to be tapped to pay for old age benefits. The United States could end up like European countries that have slower economic growth, lower per capita GDPs, higher taxes, and lower labor market participation rates.
Benefits cuts are still not happening in the United States and still seem a distant prospect. In fact, Republican President Bush added a new expensive drugs benefit a couple of years ago. No politician wants to propose benefits cuts and therefore government finances will get worse before cuts become politically feasible. Yet benefits cuts seem inevitable in the 2010s, 2020s, and beyond since the working population will oppose tax increases that are large enough to pay for all promised benefits.
Price controls are really backdoor benefits cuts. Price controls will produce decreases in the quality of service and will produce queues and rationing of the sort seen in Canada and Britain. Price controls also (and most importantly in my view) reduce incentives for development of new treatments by reducing the profits from new treatments. Hence price controls will make the financial crunch even worse by delaying the development of cost effective treatments.
Then there is the injection of more market forces into medicine. I'm all for this and favor health savings accounts for this reason. However, my judgement is that market forces alone can not prevent medical costs from becoming a huge weight on living standards because the public is going to demand governments to pay for medical bills that individuals can not afford. We are therefore politically limited in how much market forces will be allowed. Also, markets transfer the bulk of the benefits of innovation to customers and therefore underreward and underfund innovation. Markets provide even worse incentives for funding the scientific research needed to develop better medical treatments. If the government, as such a huge buyer of medical care, wants to benefit from innovative cost-saving biotechnology then the government will need to fund more research that will enable the development of that biotechnology.
Given that the four major alternatives discussed above have major downsides why not consider science as a potential solution? After all, science will eventually produce solutions that cheaply cure or prevent all the major diseases. The only question is when. Acceleration of the rate of advance could not only reduce the size of future liabilities but could also have the very attractive added benefit allowing us all to get healthier and stay healthier for much longer.
The biggest reason I can see for why medical research isn't taken seriously as a policy tool to solve the problem of unfunded old age medical care entitlements is that it is hard to predict the rate of advance of medicine. If a government wants to build a road across a continent it can get fairly realistic cost and time projections. Then the government can set out to build the road fairly confident that the goal can be accomplished in a time frame and for a cost not too far from original projections. But science by its very nature seems unpredictable. We have been pursuing the development of cancer cures for decades with tens of billions spent to date and still can't cure most cancers.
But the unpredictable nature of science ought to be considered in light of the substantial downsides of all the alternatives. We have a huge problem with aging populations. The problem doesn't get the attention it deserves in part because tallies of numbers of tens of trillions of dollars of liabilities and descriptions of trends in dependency ratios of workers to retirees and children are rather bleak to discuss and depressing to ponder. Debate on the issue easily deteriorates into a partisan battle about the New Deal and the proper role of government. Ideologues are quick to run to take up defensive positions against perceived ideological attacks by the other side, leaving them ill-disposed to think through rational analyses of the problems posed by aging populations. Does the US Social Security old age retirement program face a financial crisis? Perceived (and in some cases real) attacks on its very moral legitimacy prevents the financial problems of Social Security from being discussed rationally in too many cases. Ditto for programs for medical care for the aged. We need to move beyond the ideological sparring and look for better solutions.
Precisely because scientific research takes a long time to produce desired results we need to greatly increase the push to advance biomedical science and biotechnology now. We can't wait until the budget deficits are even larger, taxes are even higher, medical care rationing has become commonplace, the economy is stagnating, and the task of finding money to allocate to research is even more difficult. As things stand now medical treatment spending is going up faster than inflation while medical research spending is going up more slowly than inflation. Medical research spending ought to rise as fast as medical treatment spending rises.
My modest proposal for funding medical research: Change the major medical entitlements programs to require that 10% of all medical entitlements budgets go to fund medical research. Then when medical entitlements spending inevitably goes up medical research spending will go up proportionately. Yes, that will make the financial numbers for the medical entitlements programs look worse in the short run. But the money thereby spent will produce much larger savings for those programs in the longer run and will also produce treatments that will lead to great improvements in the health of the vast majority of people.
The Scientist has additional details about the NIH budget.
The proposed NIH budget would provide $15.5 billion for new (competing) and continuing (non-competing) research project grants, a 0.4% increase of $56 million. This would fund about 38,746 total projects, 402 less than this year. The average new research project grant would be funded at $347,000, about the same amount as in FY 2005.
One question I have: Is the current allocation of money in the NIH between staff researchers and grant-funded researchers optimal? My guess is that less funding for NIH staff and more funding for academic researchers would produce more total research progress. Anyone have any useful insights into this?
Well, you make some interesting points. But historically I need to point out that prior to Medicare and then Medicaid coming into existence, most everyone got healthcare. In fact, the Congressional Record on the Medicare debates talked not about elderly not getting care -- but that their dignity was offended in having to endure charity care [something we did in hospitals all the time].
If you pulled the rug out from under medicine so that market efficiences were forced upon it again, prices would collapse quickly and would rapidly become affordable for everyone.
This would also collapse drug prices and turnaround time from lab to clinic.
It would be nice if increases in medical research funding could be expected to result in cheaper and better medical therapies, but this has rarely been the case. As a former NIH staffer, I saw very few proposals that had a direct link to better medical care, and almost none that could lead to cheaper care. Most NIH research is done in animals or, at best, human tissues (e.g., studies about human DNA), and there is no requirement that the proposal explain how it will improve human health.
What the health care system needs is 'applied research' similar to that which drove Toyota to improve their manufacturing processes, or that which drove the size and cost of computer chips down. NIH research focuses on refining understanding of very detailed questions that are usually irrelevant where the rubber hits the road. And saying that it just takes time for these discoveries to reach clinical use is a smokescreen. For example, millions of dollars were spent in the 80's and early 90's on peptic ulcer disease (stomach and upper bowel ulcers), and billions were spent on drugs to treat it. Meanwhile a couple of guys in Australia noticed that some antibiotics cured this 'incurable' disease. One can understand why big pharma were reluctant to look at this, they were making a lot of money on their antiulcer drugs, but NIH and the rest of the medical establishment also had an interest in ignoring this new (and cheap) treatment. Think of the research programs that would have to find something else to do. To make a very long story shorter, it took about 15 years for this treatment to gradually diffuse through the medical system.
NIH does a great job on supporting research into fundamental questions (like what happens when you change an amino acid in the DNA of the Zebrafish), and some small part of this may someday make clinical care better (cheaper is even tougher). But if you want to improve efficiency in medical care, you need a different approach and different agency/bureaucracy to spend the money. And that agency does not exist now.
Dismantlement of the welfare state is a very distant prospect. The welfare state is going to grow larger, not smaller.
Old age medical costs in the 1960s: Yes, but far fewer diseases could be treated at all back then. It was cheap to put someone in a low tech hospital bed and bring them food as long as they could eat while waiting for them to die.
I would like to see the federal agency that administers Medicare be required by an act of Congress to spend research money for the following purposes:
1) To do trials that compare existing therapies to see which are cheaper and which work the best.
2) To do trials on new therapies that are unproven to see if they work.
3) To develop cheaper ways to deliver existing therapies.
4) To develop entirely new therapies precisely because the proposed approaches can be argued for some reason to have the potential to be cheaper.
In other words, make the biggest buyer of medical care responsible for finding cheaper sources of medical care.
SteveSC, I would differ with your criticism of NIH funding directions. The best way to reduce the cost of diseases associated with old age are to cure the diseases and/or cure aging. The fastest way to do that is research in animals and human cell culture. By cure, I mean treat the cause, not merely the symptoms. We currently do this very poorly for diseases like Alzheimer's, diabetes, heart disease, and major cancers. We need to get therapies down to a single pill. And we can do very little about aging itself right now.
Whose talking about collapsing the welfare state? Just kill off Medicare. Get the FDA out of the picture. Shutdown the NIH totally. Why is this so strange? Imagine the state of computer science if we had a Federal Dept of Computer Utilization, a New Chip Services Administration and National Semiconductor Research Institute.
Too radical. Then just pass one law. Any physician, with one third-party review and transparency, can treat any patient with any drug or device, approved or unapproved by the FDA, if the physician feels that there is benefit.
The focus on curing disease is very expensive. The preferred alternative would be prevent disease. It is exorbitantly expensive to repair the damage from fifty years of smoking, lack of exercise and unhealthy diet. From a public health point of view, huge taxes on cigareetes and sugar could finance additional health care costs plus would discourage unhealthy lifestyles. Another billion spent on encouraging the public to exercise would lower health costs in the aggregate than some billion dollar drug. The greatest increases in life expectancy in the past were the result of improved sanitation and better nutrition - not drugs. I've read that the average American takes 7 pills a day by age seventy. An eighth pill is not going to significantly help him.
It's wonderful that you are all discussing this stuff but the 800 pound elephant in the room is the blatant misrepesentation that "INCREASES" of .7% and 2.4% are "CUTS!" They are what they are: INCREASES. Even if we do not like the fact they did not go up by what we self-perceive they should, they are INCREASES.
Again, they are NOT "CUTS."
Sorry, but it frosts my jaws that liberal-speak is permeating everything in our society.
Certainly there are cheap ways to reduce the incidence of some diseases. For example, wider spread food fortification with vitamin D might be able to reduce the incidence of cancer by 30%. But it is unlikely that diet and lifestyle changes can reduce the incidence of cancer or most other degenerative diseases by more than a half. Also, obesity is caused by excessive appetite which probably can't be fixed without the development of an appetite-suppressing drug.
As for taxes on sugar and junk food: There is not a remote chance that will happen. You might as well tell me we could close all the jails if we could just convince criminals to stop committing crime. People want their sweets. They want their fat. No government that is not totalitarian is going to try to take these things away from them.
As for the 8th pill: If that pill cured cancer it would help millions of seventy year olds.
As for how improvements in health were made in the past: Yes, and transportation was improved by building paved roads. But surely there are diminishing returns to road building and to improving diets or purifying water. Suppose the average tap water in Western countries had its bacterial count and toxin concentrations cut in half. Would that reduce disease incidence by even 1%? I doubt it. We need to solve other and very different problems in order to be able to reduce the cost of treating diseases and to reduce disease incidence in old age.
We need to solve basic problems in molecular biology such as how to deliver genes into mammalian cells in situ and how to train cells to perform effectively in cell therapy treatments and to solve tissue engineering problems for how to grow replacement organs. We need lots of basic and applied research toward these ends.
In inflation-adjusted terms the budget for NIH really was cut. NIH's budget for 2004 could buy more of a market basket of commodities and products than could NIH's planned budget for 2006.
Economists routinely convert figures across years into some common reference year dollar so that useful comparisons can be done. Why? Because a dollar in one year can not buy as much as a dollar in another year. Effectively it is not the same dollar.
Public health policy is facing a crisis of rising costs.
These costs are related to the success against infectious diseases, which results in a larger older population and to an increase in degenerative diseases.
The degenerative diseases are primarily the result of lifestyle changes - poor nutrition and lack of exercise. Many of these degenerative diseases were unknown or rare in the past. Cancer and diabetes are now stiking at a younger age than ever.
Just as gas guzzling cars are affected by public policy so are poor lifestyle decisions. Direct taxes on goods are the preferred route to change behavior with externalities (economic effects beyond the individual). Taxes on cigarettes would allow each individual to smoke if he wants. On the other hand, the smokers share to supporting burgeoning health costs would be proportionately higher. And those who would abandon smoking would lower the overall health care costs.
Cutting the number of smokers in half would have an amazing effect on the overall health of the population. A single effort such as this would dwarf any immediate research efforts. The extra money for long-term, ambitious research would come from the money saved by the quitting smokers.
You are right that politically, this is unlikely to happen. The test of good leadership is the ability to take the appropriate steps before a crisis occurs. If action is delayed, a real crisis in the health care system is inevitable.
The principle would apply to other issues as well. Preserve peoples freedom to be fools, but discourage as many as possible from adding to the public burden by taxing them for foolish behavior.
In any sphere of activity, it is always more sensible to prevent problems than trying to repair the damage.
A tremendous body of scientific literature has already demonstrated that many diseases can be prevented through lifestyle changes. The search for the eighth pill is the search for a solution which allows me to continue to be irresponsible and yet not face the consequences.
Lifestyle changes are not the primary cause of degenerative diseases. The primary cause of degenerative diseases is aging. Why do we age? Because natural selection selected for metabolisms that make errors and that spew out free radicals that damage cells. Even skinny people who do not smoke, who jog every day, who eat lots of vegetables and fruit, who eat little meat (I'm describing myself btw) still grow old. People who eat wisely and get lots of exercise still become at greater risk of heart disease, cancer, Alzheimer's, and assorted other diseases with every passing year.
We need to be able to treat these diseases more effectively. Take for example the radiation, chemotherapy, surgery, and successive CAT scans and bone scans used to treat cancer. Imagine that a single series of pills taken over a few weeks could kill all the cancer cells without damaging normal cells. There'd be no need for expensive radiation machines. There'd be no need for successive CAT scans to watch the cancer's progress. There'd be no need for drugs to lessen the side effects of chemo. There'd be no need for dozens or doctor's visits or surgical teams to treat it. The savings would be enormous.
The reason sugar and fat are not going to be taxed is not because politicians are lousy leaders. The reason there will be no such tax is that they'd get voted out of office if they tried.
We need treatments that attack degenerative diseases at the molecular and cellular level. Those treatments will some day be far cheaper and far more effective than the treatments we have today.
Great post! A tough question that we must address is where we are along the learning curve. I think we clearly still chasing illness and managing symptoms. When will we "turn the corner" and start dealing with true causes? I would wager that we have a ways to go before we "turn the corner."
With that being said, we are clearly learning at a very fast rate that also appears to be accelerating rapidly. This suggests that we keep spending at a rate higher than inflation. What other social programs are still providing increasing rates of learning?
In addition, this is one area where the US still holds a strong lead with our global competition. Do we want to give this up?
Free-radicals get us all, even those with wise lifestyles. However, the degenerative diseases that are soaking up all the resources are indeed those concerned with lifestyle.
Consider the following:
" Type 2 diabetes, which was once called adult-onset diabetes because it rarely occurred before middle age, is affecting more and more children, some as young as six years.
Exact numbers are still being gathered, but many doctors say there is an epidemic of type 2 diabetes in youth. At the pediatric unit in one diabetes center, staff said they have seen a 10-fold rise in childhood Type 2 diabetes in the past decade. Complications from the illness include kidney failure, blindness, heart attacks and amputations." http://www.mercola.com/2003/apr/30/child_diabetes.htm
The finite resources for health care will be increasingly concerned with immediate crisis such as the diabetes epidemic, and not with age-reversal.
I don't think the leaders are lousy, they are just like the rest of us, reluctant to act before a crisis. Which implies -- there will be a crisis.
Our irresponsible behavior is burning up the resources that good go for better causes, such as, life-extension research.
I do not see the obesity epidemic as primarily caused by irresponsibility. There is not as much physical labor to do. At the same time, many people inherited genes that gave them strong desires to eat since in most of human history calorie malnutrition was the leading cause of death (whether through outright starvation or by increased susceptibility to infection). Cheap food combined with the elimination of all sorts of physical labor in the daily routine is producing an epidemic of obesity.
That epidemic of obesity is best stopped by the development of appetite suppressants and also drugs that cause fat to burn off.
Having said that, I think there is room for better policies toward diet. For example, get junk food out of school cafeterias and company cafeterias and replace it with lower glycemic index and high fiber foods.
Irresponsible is too strong a word, I admit. As you point out, we are designed too feast when there is a chance. But, nowadays, everyday is a feast. You favor artificial controls like appetite suppressants. I'd prefer relying on individual choice. The individual's choice should be guided by education and public policy (those taxes I mentioned, again!). The advantage of your approach is it requires less of the individual. Just pop another pill.
The appetite suppressant ,with no side effects, if it exists, would do more to reduce the health cost burden than other exotic treatments to cure incurrable diseases. Again, it's an ounce of prevention that's cheaper than a pound of cure.
How about turning physical ed into something serious in the schools. Too much emphasis is put on sports instead of shaping up the masses. The money is there, it's just not spent right.
"You favor artificial controls like appetite suppressants. I'd prefer relying on individual choice."
And what does the one have to do with the other? My individual choice would be to take the appetite suppressants and then eat less without being hungry all the time. The mental effort needed to ignore hunger can be better used elsewhere.
The best way to get cost-effective preventative measures into general use is to drop all of our encouragement for insurance companies to charge everyone in a heterogenous risk group the same rate. If people paid the going rate for their health risk the same as they did for their driving risk, they'd embrace - and gladly pay out-of-pocket for - preventative measures that justified their cost in lower risk and lower insurance cost.
Lots of great ideas in this thread. I will chime in again on a few.
1) I am going to go out on a limb and declare that no government action will EVER eliminate people's propensity to harm themselves, be irresponsible, choose poor lifestyles, etc. Consistently wearing a seatbelt increases life expectancy more than any other single action (last time I checked it increased it by 2 years) yet many people can't be bothered with this two second act. Given that people will be people, society's choice is when to step in to 'rescue' them from their bad choices. As society gets richer, we can afford more (and our standards increase also), so this will be a moving target on an upward slope.
2) If we eliminate lifestyle issues, we still have to face 'degenerative diseases' and aging. Unlike pneumonia or influenza, these are not single cause problems. A complex interaction between a person's genes, their environment, and voluntary behaviors drives problems like atherosclerosis, many cancers, etc. Eric, this is one reason that we do 'very poorly' in treating the causes of Alzeimer's etc. And because of this complexity, reductionism often doesn't work. Just because you can cure something in a mouse doesn't mean it works in a human.
Even if a 'magic bullet' is discovered, for many of these problems it will increasingly be effective only in a relatively small group (e.g., see how many of the new cancer remedies have very restricted efficacy). As the cost of each magic bullet stays the same (or worse, goes up) and the number who benefit goes down, overall expenditures will continue to climb. Also, as we age, the effectiveness of each 'cure', decline in terms of life extension. Yosef's 'eighth pill' might benefit millions of 70 year olds, but only for the short time until the next problem pops up. To use the (imperfect) analogy of a car, good maintenance and an excellent mechanic only get you so far, eventually the cost of keeping a car on the road starts climbing higher and higher. And you can replace a lot more parts on a car than with people--just think if you had to refurbish the original parts!
As an aside, in the industrialized world the major diseases are diseases of wealth. A hundred years ago only the wealthy were able to get fat and suffer atherosclerosis, gout, etc., or live long enough to get cancer. Most everyone else suffered from lack of nutrition and died of infectious diseases. If you want to see where medical problems will be 50 years from now, look at the rich (e.g., issues of cognitive decline and frailty, not as much heart disease and cancer). And these problems are even more complex.
3) Finally, leaving aside the question of whether NIH is truly improving the health of the average American, the changes in the budget will definitely cut the amount of innovative research they fund. Why? The bureaucratic processes are conservative (in the nonpolitical sense) at multiple levels. First, most research grants are for five years and have some indexation to inflation. So when the budget is flat, less than 20% is available for new grants, the rest is 'continuation' awards. Second, the review groups are highly biased towards 'experienced' researchers, so many of the new 'competing' awards go to someone who just completed a five year cycle. Since just about everyone who has an award applies for another cycle, and it is usually a continuation or variation of what they have already been doing, when the budget is flat just about no one who is new or has new ideas can get funded. This has happened several times in the past--look for dire warnings about the lack of innovation, exodus of talented young researchers, etc. As a corollary, decreases in the budget have even more drastic effects--a 10% cut would mean 50% less new research would be funded in that year.
Are you skinny? Obese people feel the pull of hunger a lot more than do skinny people. It is easy for a person with a lower appetite to just tell obese people they need to make the individual choice to eat less. But is extremely difficult for the obese people to resist the constant demands of their desires to eat more food. It is like an addiction.
No, we do not yet have effective and very safe appetite suppressants. But eventually we will have such suppressants. I would rather we have a larger research effort to get those appetite suppressants sooner.
As for whether it is a bad thing that appetite suppressants would be unnatural: We have used technology to create unnatural human environments to which humans are not evolutionarily adapted. Unless we abandon the unnatural environments and return to living more primitively the only real choice we have is to adapt our bodies to the unnatural environments we have created.
Humans are not going to return to a more primitive way of living. Therefore we must use drugs, gene therapies, and other advances to adapt ourselves to modern industrial society. I see no other choice in this matter.
My major disagreement with you has to do with the costs of future treatments. I agree with the late Lewis Thomas MD on this issue: Initial treatments will be costly. But as we come to better understand the underlying causes of diseases and develop treatments that target those causes on the molecular level the costs of treatments will drop.
Take the methods that will eventually be found to cure cancer. Once gene therapies, vaccines, and monoclonal antibodies are developed that will cure cancer the manufacturing costs to make these therapies will gradually drop and the patents on the treatments will eventually expire. Then curing cancer will be very inexpensive.
Even before the patents expire the treatments that very selectively operate just on cancer cells will be far less expensive than surgery, radiation, and countless CAT and MRI scans. Treatments that work extremely well and extremely rapidly will cost less than treatments that work only part of the time and that have to be given over years.
Also, I do not expect the newer cancer treatments to all be custom targetted to each individual. A gene therapy that restores proper functioning of p53 and a few other growth regulating genes could probably be made to be fairly generic. But even custom-targetted therapies will fall in cost as the techniques for manufacturing them become highly automated.
More generally, biotech is following the pattern of electronics technologies. Small stuff can be made more cheaply than large stuff and successive generations of technology become cheaper and more powerful.
If we eliminate lifestyle issues, we still have to face 'degenerative diseases' and aging. Unlike pneumonia or influenza, these are not single cause problems. A complex interaction between a person's genes, their environment, and voluntary behaviors drives problems like atherosclerosis, many cancers, etc. Eric, this is one reason that we do 'very poorly' in treating the causes of Alzheimer's etc.
Yes, but no. The reason we do poorly at treating Alzheimer's is because it is a protein aggregation disorder, and we don't have effective small molecular inhibitors of large protein-protein interactions -- yet -- but I know people who are working on the problem and if there were copious funding we might see a cure in 10-20 years.
Heart disease is complex, but if you can disrupt plaque formation then I imagine you're good.
Caloric restriction mimentics or SIR2 agonists shouldn't be that hard to cook up.
and so on...
Ah, reductionism raises its head! No one knows what causes Alzheimer's Disease, and although the prevailing theory is that it has something to do with plaques there are competing theories. Clinical Alzheimer's (i.e., what is diagnosed as AD by doctors) appears to be a conglomeration of a variety of cognitive disorders with varying etiologies. Even if we find the magic bullet that 'cures' the plaques, AND the plaques actually are the cause of classic AD, we will be stuck with a bunch of Alzheimer's-like disorders that still have to be treated.
I agree that the costs to treat any particular disease are likely to drop. What won't drop is the cost to treat the problem. Let me explain the difference. An antibiotic can effectively treat an infection by a susceptible organism in a immune-competent host. The disease (that particular infection in that particular host) is treated and as time goes by the costs for similar treatment declines. Infectious disease as a problem has been whittled down so that other problems (e.g., heart disease) have bumped it from the top spot. But the problem of infection has not gone away, and overall costs are still high (e.g., AIDS, resistant Staph, etc.). Ultimately, many people still die of infection after other diseases increase their susceptibility. Christopher Reeve did not die of his spinal cord injury, he died of an infection from a pressure ulcer.
Cancer will follow the same path. As we age our cells accumulate genetic errors, and some of them can trigger a cancerous conversion. We can find the 'antibiotic-equivalent' to each type of cancer, but as the errors mount, the number of cancers in a particular person will crescendo. 'Easy' cancers will diminish in importance, and 'resistant' cancers will create most of the problem and cost.
Does this mean I am pessimistic and don't support cancer (and other medical) research? By no means! If we can cure 98% of cancer it will reduce a lot of suffering. But the remaining 2% will still be costly. And a different medical problem will be 'uncovered' and cause problems. This is why, despite all the medical successes, we spend more and have more problems now. If most of the population is malnourished and dies quickly from infection, costs (of medical care at least) are pretty low.
BTW, the great success of the electronics industry is that it has minimized complexity! By keeping digital even very complicated chips have predictable responses (I am using the word 'complicated' here to mean 'made of many parts', while 'complex' means a system whose responses are unpredictable due to non-linearities). Whenever the electronics industry treads near complexity (e.g., Windows) spectacular problems occur and the engineers back off into systems that are more predictable. One of the reasons electronics and medicine are difficult to combine is that a complex system typically 'infects' a non-complex one, making it complex. Hopefully someone will find the way...
The only reason that reductionism is ugly is that the truth is sometimes ugly - at least to some minds.
A few years back a vaccine to amyloid plaque halted the progress of Alzheimer's in a number of patients. The trial was stopped because some rather small percentage of the patients developed an immune response that caused brain inflammation. The trial struck me as strong evidence that if we could only remove the plaque we could probably stop Alzheimer's,
Parenthetically, it infuriates me that the current regulatory regime would not allow this vaccine on the market due to safety concerns. If I had Alzheimer's I'd want to take the vaccine immediately and accept the risk of brain inflammation. The alternative of not taking it has such a gruesome and horrible outcome that even the brain inflammation seems preferable.
Crescendo of cancers: It depends on how cancer is treated. First off, if a gene therapy could be devised that would go into all pre-cancerous abnormal cells and either fix or kill them off then the crescendo of cancers could be avoided entirely by delivery of such a gene therapy once every several years. My guess is that even once a decade or longer would be adequate.
I believe it will be possible to develop gene therapies - perhaps coupled with monoclonal antibodies - that would target and enter a substantial portion of pre-cancerous cells. Ditto for targetting senescent cells. Granted, there might be cells that will not present an antigen signature that marks them as abnormal even though they are abnormal. But my guess (and this is only a guess) is that before cancerous cells mutate into a form that produces angiogenesis-promoting compounds the vast bulk of them will look different from the outside or can be induced (perhaps by some pharmaceutical compound) to look different for a gene therapy delivery vehicle to recognize them.
As for complex chips having predictable responses: Actually the average complex chip design has a long list of errata listing unexpected and undesired behaviors and those listed errata are often a subset of a much larger list of bugs. Hardware has a lot of bugs. Software has lots of bugs. We can't design complex systems without having unexpected behaviors. We can't even come up with comprehensive lists of requirements that describe in detail all expected behaviors. I say this as someone who writes and debugs software all day, who has written numerous work-arounds for hardware bugs, who has written code to exercise poorly documented and buggy hardware to figure out how it works, and as one who has sat in a CAE chip design lab with a bunch of digital EEs writing simulations to test a new processor design.
I guess we will just have to wait a few decades and see what happens ;-)
I would agree with you on the regulatory issue except that, unless the legal climate changes, pharma companies would still avoid marketing a 'dangerous' drug until it has completed FDA review.
Your last point is exactly what I was saying about electronics. All that time you spent debugging, writing work-arounds, and doing simulations are attempts to define or create boundary conditions within which the responses are predictable. Yes, software and hardware have 'features' which are unpredictable and are ultimately complex systems, but, in my experience, a well-engineered system is pretty predictable within the parameters it is intended to operate (outside those parameters is another story, of course). Also, it is my understanding that many systems are engineered to shut down on failure, to further limit unpredictability. Unfortunately, in medicine it is pretty hard to shut down and reboot (although some of the paralyzing and cooling techniques in brain surgery and trauma are getting close).
Did we forget the big picture? We should be thinking about who prescribes us those pills. We wont even have the doctors we need to feed us the pills unless we do something about our health care work force.
A 2005 report in the New England Journal of Medicine said U.S. medical schools, which currently graduate about 25,000 medical students a year, need to train an extra 3,000 to 10,000 to prepare for the growing medical needs of aging baby boomer's and the rest of the nation's growing population. It takes 10 years to train a doctor, so the United States could be short 85,000 to 200,000 doctors of all kinds by 2020 unless something is done, the report warned.
Declining birth rates mean that societies everywhere will soon be aging to an unprecedented degree. Increasing life expectancy is also contributing to the aging of the world’s population. In 1900, American life expectancy at birth was 47 years. Today it is 76. By 2050, one out of five Americans will be over age 65, making the U.S. population as a whole markedly older than Florida’s population today.
What I am getting at is that pills wont matter if we don't have an economy to buy them with or the ability to care for ourselves.
I think we need to get our priorities straight and focus on a much bigger problem of where are we going to get the people to take care of us now that WE are living so long and how are WE going to pay for it.
I say cut out the waste and automate medicine. Instead of training more doctors increase the productivity of those who are already practicing.
Also, if we accelerate the rate of advance of medicine we can develop methods to reverse aging. Youthful rejuvenated bodies will not get sick and will not need as much medical care.