Personalized medicine: a bridge too far

The Weekly Packet.  September 28, 2016

I captured the hummingbird images accompanying this posting while sitting quietly on our deck at camp. They are fascinating creatures. (If you hover over the photos, you should be able to click and get full-screen images with camera data.)

I ‘m leaving in two days for a short fly-fishing trip to Lewis and Clark country with a local group; we’re fishing the Missouri outside Craig, Montana. It will be a chance to tune out the clamor of the election for a couple of days, and I look forward to it.

Meanwhile, I want to direct your attention to a couple of items that caught my eye recently. The first was a comment in a New York Times article that referenced a piece that appeared in Slate. The data are well-referenced, and even if off a few percentage points one way or another, they are frightening. No, not the latest election polls, but the fact that more than half the world’s population does not have access to flush toilets. In fact, yesterday the Science section of the Times reported that a half-million homes in the US don’t have adequate plumbing. Simple sanitation, with sewage treatment, access to clean water for washing and drinking, and preventive immunization are the foundations of public health.

The second issue is a World Health Organization report that appeared on Sept. 27th, and was the subject of a New York Times piece by Mike Ives. The data indicate that over 90% of the world’s population breathes air with unsafe levels of fine particulates. Perhaps just about now, many of you think I have gone off some sort of deep end. Give me just a second. My older son, David, is an environmental economist who has worked on the health costs of particulate pollution for a couple of decades. The health costs are real and well-documented.

Recently my former chief at the Cleveland Clinic, Eric Topol, published a book titled The Creative Destruction of Medicine. In it, Eric advocates for his view of highly personalized medicine with management informed by genomics and driven by constant data acquisition using smartphones or similar devices. My simple view is that genomics and personalized medicine is a bridge too far in the war on disease when millions of humans don’t have toilets, and few of us can avoid inhaling particulates with every breath. And when our ageing infrastructure holds the potential for many more Flints here at home.

The official White House website   https://www.whitehouse.gov/the-record/climate  states that President Obama believes, “no challenge poses a greater threat to our children, our planet, and future generations than climate change.” Whatever your political persuasion, I think we can all agree that the President is a bright man who has a remarkable context in which to decide what issues merit the most concern.

I think those of us in medicine and in the pharmaceutical industry have a responsibility to the public. We continue to see hospitals competing with ads for their cancer centers, heart centers, bariatric programs, and joint replacement surgeries. We continue to see drug companies advertising new agents with short spots that build unrealistic expectations of benefits and minimize risks. Let’s speak up to the public through our professional organizations, and push for a few years of redirecting these institutional advertising budgets toward real public health: clean air and clean water!

Nesiritide. The Rise and Fall of Scios

The Weekly Packet has not been posted weekly for a couple of weeks! I’ve been hard at work wrapping up the details of my book, Nesiritide. The Rise and Fall of Scios.

Nesiritide is now available, paperback and hardcover, on Amazon. 

When I started trying to find an agent, I sent out over four dozen queries. The agents who replied told me they did not think I would have a very large potential readership. I hope to prove them wrong.

Most of you who have visited this site are friends who know parts of the Scios story. I think you will enjoy reading the narrative, and I hope you will tell your friends, neighbors, and co-workers about it.

Now that it’s out, I will get back to regular posts.

What’s been happening?

 

I hope that a lot of Americans are willing and able to do what I did last week. I turned off the television and radio news, saved the interesting parts of the newspaper to review this week, and went fishing.

Surprisingly, my actions had no discernible impact on world events. The butterfly effect may be true for weather, but not for my contribution to the overall clamor.

Here’s some of the stuff I saved, in no order other than the random pattern in which I pick the articles up.

Peter Loftus, writing in The Wall Street Journal for Wednesday May 11th, reported that Cigna and CVS Health Corp. (the second-largest PBM in the US) have negotiated outcomes-based pricing for PCSK9 inhibitors, as well as some other costly drugs.

In The New York Times “business day” section of Wednesday, April 27th, Katie Thomas reported that pharmaceutical companies raised list prices for a number of brand-name drugs. You have to read the whole article to learn that overall list prices rose 12%, but actual net prices increased 2.8%, “one of the lowest increases in years.” One expert, commenting on the current pricing issues, said “it’s so complicated, you can’t really unwind it without blowing up the entire health care system.” That was before the outcomes-based pricing negotiations!

Finally, in the next-to-last paragraph, of the 4/27 article, came the real issue. “Specialty drugs…now account for 33% of all drug spending even though they [are used to] treat about 1 to 2% of all patients.”

The New York Times “national” section, Thursday May 12th broke the headline news that more than 1 million people in Texas now have active handgun licenses. The initial application costs $140 and renewal is $70. There is a discount for low-income applicants.

Finally, if you look a little bit deeper into all the fuss about Valeant Pharmaceuticals and the price rises the company has imposed, the two big-issue drugs that reporter Anne Steele mentioned in The Wall Street Journal on May 17th are isoproterenol and nitroprusside. Ms. Steele did not say what percent of the nation’s drug costs are spent on isoproterenol and nitroprusside, but I suspect that handgun license fees in Texas alone might well cover it.

So, here’s an idea. The people who are telling us the news, even the best of them, want to do it in a way that excites us, raises our hackles, and fires us with indignation. Let’s slow down a little. Spend a couple of hours outdoors, with the dog or the kids. And let’s try to put some of these hot-button issues in perspective.

The land of giants

As promised, here’s a look at Patagonian Chile.

Chileans are, for the most part, warm and friendly. Our flight from Atlanta arrived in Santiago about 3 hours late. Standing in line waiting is one of the popular national activities in Chile, and we had to cut a few lines to make the next flight. Although we could not apologize in Spanish, people were kind, smiled, and let us hurry along.

The road trip photos demonstrate the huge civil engineering task the Chileans face, first in completing the task of constructing and paving the Carretera Austral, and second, of driving on it in with the local cows enjoying a break.

One of the great joys of fly fishing is the travel to spectacular places. The mountains and forests form “the wilderness without teeth.” It’s wild country, but with very few large animals. Patagonia just does not have the large top-of-the-food-chain carnivores (i.e., bears) that we do in North America. The sound and fury of the primaries did not make the faintest echo in the mountains.

Europeans introduced trout into South American waters around the beginning of the twentieth century, and the fish have thrived. They grow fat and strong in the clear, cold water of the rivers that run down out of the hills toward the Pacific. Patagonian Base Camp sits on the banks of the Rio Palena, and provides opportunities to visit many of the nearby streams.

Next week, I’ll return to more serious subjects. For now, have a look at the photos, imagine the stars of the Southern Hemisphere spread out in a moonless sky a hundred kilometers or more from the nearest town, and imagine the sound of Rio Palena hurrying past. What a wonderful trip!