Dr. Zerhouni spoke at the Washington Biotechnology and Biomedical Association (WBBA) annual meeting on Friday November 6. His role as director of the National Institutes of Health gives him a unique perspective at the intersection of science and public policy. He introduced his talk by paying homage to Ted Kennedy assuring us that the tone and content of the current debate would be far different if Kennedy were alive to influence it.
“Life Sciences will be for the 21st Century what physical sciences were for the 20th” - Senator Ted Kennedy as quoted by Dr. Zerhouni
The worldwide cost of healthcare is rising at rate that is truly frightening. While the bills being debated in Congress now will help to increase coverage, their effect on the rise in costs is likely to be marginal because they are focused on incremental changes and not structural problems. Dr. Zerhouni offered his list of some core issues:
- Progress in acute care has caused a shift in healthcare from acute to chronic care as people live longer. Unfortunately care for chronic conditions is more expensive.
- Aging populations shift the cost structure of medicine and our models for geriatric care have not adjusted quickly enough.
- There are huge disparities in both health status and health care regionally. It is difficult to believe that one top-down system can address them all well. Healthcare in rural Louisiana is radically different in both its goals and outcomes from healthcare in Boston.
- We face both emerging and Re-Emerging diseases. Depression is emerging as one of the largest causes of disability in our country. And the dynamism of the world economy allows diseases that jump species into humans to rapidly become global threats. On the other hand “solved” acute conditions can reemerge because of health practices throughout the world.
- Obesity is a growing problem worldwide and it is insidious because solutions require difficult changes in lifestyle.
The majority of total healthcare costs are for chronic conditions. For those conditions, the cost curve rises dramatically as diseases progress from pre-symptomatic through symptomatic to critical. The opportunity for maximum savings is for early diagnosis and treatment but the current reimbursement system only pays for care after the disease is established. Treating before there is actual biological damage is dramatically cheaper.
4P medicine (Personalized, Predictive, Participatory and Preemptive) is an approach to radically changing the cost basis of healthcare. But the evolution to this paradigm will require social changes as well as technological. In order to make significant progress we need to change focus from health care to health. Imagine a world where elections were influenced by how well a constituency had progressed in key success metrics such as BMI or lifespan.
A major key to 4P medicine is to improve the diagnostic capabilities of clinicians in order to evolve to a world of precision medicine. In recognition of the financial opportunity that this represents, private funding of research has grown considerably faster than public funding. The crossover point was roughly 1991 and now private funding is roughly 2x the NIH budget. Unfortunately the productivity of research has declined for a number of reasons:
- Many of the current needs are met by current therapies
- Given the drugs that are available, new candidates compete against the best in class of existing drugs and not just placebos
- There is a lower tolerance for risk and failures are highly publicized
- Biology has proven to be more complex than expected – there was a time when we thought that simply cataloging the genome would be sufficient to make a large impact on health
- The regulatory burden is higher and our ability to predict toxicology is not very good
In many ways the effort for Translational medicine is walking backwards because of risk aversion and the lack of interdisciplinary approaches.
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