Health Insurance Is Not
Health Care Is Not Health: Redefining the Goal of Medicine
By
Leonard Zwelling
http://www.nejm.org/doi/full/10.1056/NEJMp1506241
“The 21st
century is the century of biology. The nation that invests in biomedical
research will reap untold rewards in its economy and the health of its people”
Dr. Francis Collins, Director of the NIH JAMA 313:131, 2015
“We worry that unstinting
focus on precision medicine by trusted spokespeople for health is a
mistake—and a distraction from the goal of producing a healthier population”
Bayer
and Galea, NEJM 373: 499, 2015
“Public Health in the Precision-Medicine Era”
That last quote is from the reference the link to which is
given above.
In what ought to be an article of earth-shattering
importance, but will likely go unnoticed by the lay press, these two public
health experts take a long step back from the precipice of the abyss into which
most everyone in academic medicine has already jumped. That hole is genomics.
This is no more germane in any discipline of medicine than
it is in oncology. No greater example exists than MD Anderson, the Moon Shot
Programs and the drug company that is IACS.
Behind the manifold attempts to convince the world that
medicine has reached a point where it is smart enough to predict the behavior
of tumors and use the DNA codes found in explanted patient samples to structure
curative therapies, is truly disordered thinking. That is clear in this NEJM piece.
The argument is a simple one. What is a good metric for the
quality of medicine in a political entity like a country or state? The best
answer is the health of the people in the political entity. As a political
entity, the United States has a dreadful health record. We spend more than any
one else. We live shorter lives than our allies in many advanced western
societies, and the entire medical system is geared toward spending money treating
the individual with the hope that this will translate into societal health.
This premise is wrong and it has failed. Despite this, all of academic medicine
and much of private practice is based on the notion that just a bit more
knowledge of biochemistry, genetics or pharmacology (or perhaps a lot more
money), will lead to major cures of chronic diseases and increased life spans
as well as life quality for our people.
Even the President has extolled the virtues of “precision medicine” (I
guess it has been imprecise for the last 5000 years) and is increasing funding
to the NIH with the promise that the research supported by the government through
RO1 funding will lead to new breakthroughs in cancer, heart disease and
diabetes treatments.
The NEJM article
makes it clear that life style, poverty, income inequity, racial disparity and
money (or the lack thereof) have far greater effects on the health of the
nation than do sequencers, “Watsonized” data bases, or overly costly electronic
medical records and designer drugs. We act like we can spend our way out of
this poor health dilemma by putting more resources into individualized care and
research. It is simply untrue.
In a phrase by Bayer and Galea, “health is determined by far
more than health care.”
The real solution to our health crisis (not health care or
health insurance crises which pale by comparison) is to address the very social
ills brought to the public consciousness by the police actions on unarmed black
men and women and the violence of the mentally disturbed on unwitting citizens
in movie theaters while most police try to keep us all safe.
In oncology, this means that the most important
translational research at MD Anderson is being done in the Prevention Building
not on the South Campus or in IACS. If MD Anderson really wants to be a citizen
of good will in Houston, make all cancer screening recommended by the US
Preventative Service Task Force available to all in Harris County who desire it
on demand for free. Oh, that might constrain a Moon Shot or two, but perhaps in
a few years no one in Houston will die of colon cancer and no woman will
present to an MD Anderson or an LBJ clinic with disseminated breast or cervical
cancer ever again.
Imagine.
The genomic hypothesis in cancer that somehow sequencing the
genes of a human malignancy will lead to better treatment and longer life spans
has yet to be demonstrated to me. Can selected examples be given where
cytoreduction based on genomic-guided drug selection has worked? Yes. Has it
yielded protracted or wide spread survival? Not yet. And given what we know
about the heterogeneity of human cancer and its genetic instability as well as cancer’s effects on the microenvironment, largely poorly described as of yet, we
wouldn’t expect any of today’s miracle drugs to be miraculous for long.
Besides, if cancer were cured tomorrow, the average life span of Americans
would only increase by 3.5 years. That’s a meager target when compared to
preserving the health of the youngest Americans through access to good
nutrition, pre-K education, full vaccinations, and enlisting everyone in the
battle against obesity, dirty air, and climate change.
The NIH stands for the National Institutes of Health. Not
the National Institutes of Health Insurance or Health Care. If the NIH really
wants to effect change in the health of Americans, fund more grants on
prevention and fewer on sequencing, unless it is sequencing the bacteria in the
microbiome, an as yet untapped source of understanding human health and disease.
To think otherwise is disordered, fuzzy and all too common.
Read
the article. Then let’s talk.
