The End of Socialized Medicine & Cherry Garcia

On June 19 1987 Ben & Jerry’s introduced Cherry Garcia in honor of the man who played lead guitar for the Grateful Dead.

The Food and Drug Administration struck back three months later when it approved the first of a new family of statin drugs that curb cholesterol production in the human liver. A synthetic statin licensed a decade later would become the most lucrative drug in history. At its peak Lipitor was streaming $14 billion a year into Pfizer’s coffers.

Let’s not blame the victim: we don’t choose Cherry Garcia; it chooses us. Lipitor is a lifesaver for 600000 genetically unlucky Americans who harbor a bad-cholesterol gene or two on chromosome 19 and for another 100 million victims of our supersize-me culture. Fourteen billion dollars is a bargain for problems as pernicious as these.

Or is it? Let’s blame the victim. The human body is so comfortable with fat that it rarely complains about a cholesterol glut in the blood until seconds before things crash. Medicine has never seen—nor much needed—anything like this biochemical arsenal before.

Many who should be worried never even get their blood checked. Many who do check it fail to take their Lipitor. None of us really needs the pill anyway—just lose the ice cream shed the pounds stop smoking and exercise regularly. Lipitor is a chemical version of the bulimic’s finger down the throat.

Call it tuning if you prefer. Lipitor tunes our cholesterol. Anti-stroke medicines tune our platelets antidepressants our serotonin and dopamine heart medicines our angiotensin-converting enzymes contraceptives our estrogen. Cancer drugs tame or kill our own mutant genes. And for every drug to suppress chemical excess there’s another to address deficits: insulin for the underperforming pancreas clotting factors for bleedy blood Synthroid for the tired thyroid and cancer-suppressing proteins to lend a hand to tumor-suppressing genes.

People-tuning drugs aren’t all new—aspirin it turns out is Lipitor for inflammatory prostaglandins—but the speed at which they are multiplying is very new. So too are the cost complexity and the sheer audacity of medicine’s new mission: to bottle an upper or downer for every last molecule that makes us tick or gums up the works. There’s still far more of this in the lab than in the pharmacy.

Doctors and hospitals spend most of their time grappling with its cumulative effects. Most of our drugs are prescribed to neutralize it. Some people are still attacked by microbes but such assaults from the outside aren’t the big problem any more. The cholera of our times is a stew of specific discrete molecules concocted by genes gluts of cigarettes beer ice cream and other delicious consumables and by whatever attitude problems we might have about eating our peas or taking our pills.

The new medicine offers instead something that the old never could: personal control. Human chemistry is much more complex but comparatively slow and stable. And molecule by molecule medicine is now making it visible predictable and tractable.

This great etiological shift—from the medicine of us versus germs to the medicine of us versus us—upends everything.

Disease and its cures now depend on factors too fragmented for conventional insurance pools to contain too costly for public treasuries to underwrite and too divisive for public authorities even to discuss much less manage.

The era of big government is over in medicine too. Within a decade or two a charismatic president will deliver on the promise to end health care as we know it. Science will discover competition will supply patients will choose and freedom will deliver better medicine and far better health at lower cost to many more people.

Asian-American women have a life expectancy of almost 87 years; African-American men 69 years. Women in Stearns County Minnesota live about 22 years longer than men in southwest South Dakota and 33 years longer than Native American men in six of that state’s counties. The gap between the highest and lowest life expectancies for U.S. race-county combinations is over 35 years. Some race-sex-county groups typically die in their nineties others in their fifties.

Factoring out wealth race and access to health insurance doesn’t eliminate most of these disparities.

Low-income whites die four years sooner in Appalachia and the Mississippi Valley than they do farther north. The healthiest whites are low-income residents of the rural Northern Plains states. In the West American Indians who remain on the reservation die much sooner than whites.

What accounts for these cavernous differences?

Harvard dares to name six leading “risk factors” for the population as a whole—alcohol tobacco obesity high blood pressure cholesterol and glucose—and reports that these factors correlate strongly with the spread in life expectancy across its Eight Americas.

A molecule can change your life quite as much if not quite as quickly as standing at the wrong end of a bullet or a speeding truck.

The first vitamin was isolated in 1912. Others followed and chemists soon found ways to extract or synthesize them cheaply. Prodded by private charities medical associations state health authorities and federal guidelines major food suppliers eradicated rickets scurvy goiter beriberi and pellagra by returning to their products what they had inadvertently removed; they also improved infant health enormously by fortifying flour milk and salt and promoting the consumption of cod-liver oil by pregnant women. By 1950 the Flintstoning of the American diet was routine and the national menu was back to healthy again or so many people thought.

They too were wrong. By 2005 seven of the world’s ten most profitable drugs owed most of their success to our foolish mouths.

Two of those drugs lowered cholesterol one suppressed the blood’s tendency to clot on cholesterol plaques one lowered high blood pressure caused in part by clogged arteries two were for heartburn and acid reflux and one was for asthma often aggravated by cigarettes.

In Western countries smoking still causes more deaths than all other readily preventable causes combined but gluttony is catching up. It’s now responsible for 350000 preventable deaths in the United States every year including about one-third of all cancers.

Cholesterol was one of the first molecules to emerge from the disassembly of glut-and-gene statistics because it plays such a big role in gluing us together. I it does depends so much on whom it’s gluing. Thin families are all alike but every fat family is unhappy in its own way.

About one in three Americans officially has fat blood—cholesterol tagged somewhere between a trifle chubby and obese. The main cause is a chubby diet but some bodies handle their Cherry Garcia worse than others. About two people in 1000 are born with a bad-cholesterol gene. Their livers can’t handle cholesterol as well as their mouths can and they’re 20 times more likely to suffer a heart attack before 60. About one in five is born with two copies which more than doubles the risk.

Genes are the other big part of the story as they quite possibly were with Nuland’s unhealthy executive. At least 3000 distinct genetic links to disease are already known or suspected—for heart disease and diabetes; for breast colon kidney prostate and dozens of other cancers; for arthritis Alzheimer’s cystic fibrosis Parkinson’s and Huntington’s disease; and for porphyria the nervous-system disorder thought to have afflicted King George III. Nuland’s brother and one of his parents both died of colon cancer.

“The best assurance of longevity” he notes “is to choose the right father and mother.”

No such rumination about personal frailties was required when the authorities opened London’s assault on cholera in the mid-nineteenth century. To be as infectious as they are germs must use public transit—the common water or air most typically—and they must target common human chemistry—the bacterial peg must fit neatly into some chemical hole that most of us share.

The difference between medicine’s old simplicity and its new complexity is rooted in molecular biology. And the germ of a biochemically unique disease may lurk in any one flawed gene or combination of antagonistic genes or confluence of genes and lifestyle.

By scrutinizing differences in our chemistry biochemists can now disassemble glut-and-gene diseases into molecules that can be exposed long before they morph into plaques clots tremors tumors occluded airwaves clogged arteries and failed muscles. Breast cancer used to be a lump; now it’s at least four genes two of which when paired make a tumor almost certain.

Alzheimer’s disease has been linked to four genes. Autism may result from glitches spread across 100 or more.

Perilous-lifestyle genes control hormone levels brain chemistry nerve functions and metabolic rates which in turn influence stress pleasure irritability aggression impulsive behavior suicidal tendencies alcoholism and sexual appetites. The Y chromosome seems especially toxic—men are far more self-destructive than women.

But the relentless advance of molecular science is outing them all regardless. Medicine’s principal mission today is to provide antidotes to the unhealthy side of human diversity diversity defined by our own fissiparous chemistry.

Because they treat our differences not what we share the new drugs cost far more than the old. Brewing huge vats of penicillin or Lipitor is quite cheap. The expensive part—$1 billion or so per drug—is discovering the recipe and selling it to regulators insurers doctors and patients.

Most of that billion is spent before the first pill is sold; the per-patient cost depends largely on how many people the pill then treats. A disease with four separate genetic roots probably requires four miracle drugs on the shelf. “Pharmacogenomics” fragments things further still by tailoring drugs to patient-specific genes.

From here on out cost—rather than any shortage of targets or biochemical know-how—will determine how fast drug companies develop and license new antidotes to human chemistry.

There will be thousands of people tuners in the arsenal before anyone is rash enough to announce that we have human chemistry fully under control.

And the announcement will still come too soon. Biochemists have already identified one “grim reaper” gene and several “fountain of youth” genes which point the way to lots more beyond-perfect pills. “The first person to live to be 1000 years old is certainly alive today” declares Aubrey de Grey a Cambridge University geneticist. “I am working on immortality” says Michael Rose a professor of evolutionary biology at the University of California Irvine.

Finishing the job could take time—the science and medicine of fragments won’t soon coalesce into a clear picture of how all the bits and pieces interact.

But medicine does now have a deep biochemical logic that sharply separates it from its past.
Most fundamentally molecular medicine puts the patient in control. It tells him where his personal gluts and genes will probably take him years from now and exactly how to dodge destiny by downing less ice cream or more Lipitor.

The patient with this much personal control in easy reach will also at some point come to be viewed as responsible for failing to do the right thing.

So what will insurers do with the pill that leaves the kick in a pack of Marlboros but magically neutralizes the poison?

Will Aetna and the surgeon general both celebrate this miracle drug congratulate Pfizer for racking up $40 billion in new sales in just one year gracefully accept their respective shares of the bill and watch calmly as smoking rates ramp back up?

Will Congress declare that every smoker needs this drug every smoker must get it and Pfizer’s price gouging must end at once?

Or will some heartless bookkeeper in Hartford or Washington dare to suggest that enough is enough smoking is foolish and the smoker can jolly well pay for the pill himself—or failing that for his own cancer emphysema and heart disease?

Common as they still are insurance systems that pool health risks indiscriminately are vestiges of the past. They can’t survive what lies ahead.

Insurance makes sense for risks that people can’t control. Or to put it more bluntly socialized medicine was a smart idea back when medicine was too stupid to halt infectious epidemics discourage suicidal lifestyles or discern the perils in killer genes.

But we’re now past the days when infectious diseases were the dominant killers and heart attacks and lung cancer seemed to strike as randomly as germs. And insurance looks altogether different when your neighbor’s problem is a persistent failure to take care of himself. Many people willing to share the burden of bad luck eventually tire of sharing the cost of bad behavior.

Now consider what that does to insurance economics. Most critics of the status quo focus on the more manageable of the two core problems that health insurers now face: runaway cost.

But the real problem is that for many people health care is getting cheaper. This is what makes actuaries wake up screaming in the night: disease is coming out of the closet and the new medicine splits health-care economics in two.

No one-size one-price insurance scheme can keep people happy forever on both sides of this ever-widening divide. Aetna can’t offer uniform coverage to individuals who face radically different risks and who know it too. Governments can’t either.

The new medicine winds up rationed by slow-rolling many new pills.

If they were allowed to private insurers would respond with policies openly tailored to molecular profiles and priced accordingly. Insurers already do quite a lot of that kind of tailoring indirectly by insuring through employers—work often segments insurance pools along lines similar to those flagged by Harvard. Any private insurer that fails to push this kind of segmentation as far as it can will end up covering all the heart attacks while competitors underwrite the low-fat or high-Lipitor diets.

Governments don’t face the risks of competition so they can insure as indiscriminately as taxpayers will allow. But however it’s packaged and peddled universal health insurance requires steadfast public support—and the political center just won’t hold.

Governments are impatient however especially when they have promised to supply what they can’t possibly afford but can readily seize. The promise of universal care implies state-of-the-art care so governments’ principal response has been to skip straight to the three-cent pill.

Drug companies however are quite smart enough not to develop three-dollar pills for three-cent buyers. Collectively these price-depressing strategies already make it unprofitable to pursue many drugs that treat rare diseases and drugs for all but the most common diseases earn most of their profit in the unregulated U.S. market. From Big Pharma’s perspective we are now about half a country away—the rich-America half—from making most diseases too thrifty to bother with.

Every new scheme to undercut the value of an existing patent lowers the incentive to discover new drugs. Every such scheme sacrifices long-term global health for short-term political gain. Every last one of them is ice cream today and never mind about tomorrow.

That is the real crisis in health care—not medicine that’s too expensive for the poor but medicine that’s too expensive for the rich too expensive ever to get to market at all. Each new billion-dollar Lipitor will be delivered—if at all—by the lure of a multibillion-dollar patent.

The only way to get three-cent pills to the poor is first to sell three-dollar pills to the rich.

The fastest way for Washington to deliver more health more cheaply to more people would be to unleash that capital by reaffirming patents and stepping out of the way.

Neither Pfizer nor Washington can ever stuff health itself into a one-price uniform One America box—not when health is as personal as ice cream genes and pregnancy not when every mother controls her personal consumption of carbs cholesterol Flintstones and Lipitor.

But the thought that government authority can get more bodies in better chemical balance than free markets and free people is more preposterous than anything found in Das Kapital.

Freedom is now pursuing a pharmacopoeia as varied ingenious complex flexible fecund and personal as life itself and the pursuit will continue for as long as lifestyles change and marriages mix and match.

Given time efficient markets will deliver a glut of cheap Lipitor for every glut of cheap cholesterol. And given time free people will find their way to a better mix.