We all want to live longer
It is clearly an historical ideal to live longer. We all, for the most part, desire not to die anytime soon. I am sure that for most of us it is a completely natural instinct to continue to live. We often find it morally abhorrent to want to die prematurely – like from suicide. It would be completely counter intuitive from what we know about the survival instinct, and the laws of natural selection to decide to become premature feedstock for the organisms that prey on us. Our individual desire to survive is primitive and persistent for most of our lives. And it is safe to say we have been built this way!
Google plans to conquer death.
Recently, Google, the people that brought us ubiquitous search and became known for their informal corporate policy, “Don’t be evil” – announced that they have set up a division to conquer death. Named Calico, CEO Larry Page announced that Apple chairman Arthur D. Levinson will head up this organization.
Levinson and Page have properly reset expectations for the long term results for curing death to focusing on something a little more simple and immediate like curing cancer and other such things. While curing cancer seems like a big deal to most, Page also said, “Curing cancer would only add 3 years to people’s average life expectancy.” Page wants to instead focus on eliminating a greater spectrum of aging problems. It may be wise to not focus too heavily and capriciously on “curing” cancer as a goal because so far cures for cancer have been few and far between.
The idea of conquering death is such a grand vision – a moonshot in Google-speak. It takes the concept that money, science and technology can “cure” everything to a whole new level! It also begs the question, “Can money, Science and Technology really cure everything?” A more appropriate question is, “Can money, science and technology actually cure anything?”
Can we cure everything?
Take cancer for instance, we have spent trillions of dollars, over many decades, in a quest to find a cure for cancer. We have found some ways to treat cancer. We have found some indications that DNA – genetic markets – can give us indications of a propensity to get cancer. We have even, more recently, found other protein bio-markers that may provide methods to detect specific types of active growing cancers, like breast cancer, in general body fluids, like saliva. Yet, we still have not found a cure for cancer. In fact, we disagree, on whether there is a single cause for all types of cancer or if there are in fact multiple cancers and multiple causes. Once thing that is clear after many decades, and many trillions of dollars, is that it does not appear we will have a cure; or even a good enough understanding of what cancer is and how it works to have a real cure, or cures anytime soon.
What is a disease?
The question, “What is a disease?” seems relatively simple. But, like most other things in healthcare, it is not simple at all. We have devoted billions of dollars and years of effort to mapping the human genome. We began the process with the idea that DNA, and the genome, would become the be-all and end-all of the science necessary to finally understand how the body, disease, and other things worked. Along the way, we have constantly felt that the single answer we needed to achieve the dream was right around the corner. But, the reality is that this has been a torturous and long city block in order to get even close to this corner. Now that we are getting close enough to catch some fleeting glimpses of what may lie beyond, we are starting to see some startling ideas emerge. First, we are becoming aware that there may be another critical chemistry that works in the body. While DNA is the blueprint for design, there is another tool-set at work that controls what things do and how they do them. Dubbed the “Epigene,” only in the past few years, are we getting some glimpse of what it may be and how it might work. What we have learned is that the the reality of DNA as the magic bullet of for diagnosis and treatment has fallen short of our early expectations. Another of these fleeting glimpses from around the distant corner is even more startling in its ramifications. This glimpse raises questions that reach to the very core of what the definition of disease really is.
“disease /dis·ease/ (dĭ-zēz´) any deviation from, or interruption of, the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.”
A few of the brave researchers, who have taken a glance around the far corner, are now pondering if what we call cancer really is a disease. Okay! I can hear many of you shuffling your papers, and tapping on your keyboard! I can almost hear what you’re thinking “…OF COURSE ITS A DISEASE! PEOPLE ARE HURT BY IT, FAMILIES ARE DEVASTATED FROM IT AND MANY PEOPLE DIE AS A RESULT OF IT EVERY SINGLE DAY! IT HAS TO BE A DISEASE!!!”
This is all true. We believe that anything that impacts us individually, or attacks members of our family or circle of friends is harmful and therefore it is abnormal, unnatural. We tend to perceive everything we experience, healthcare even more so, as individuals. We innately feel that whatever is good for us – and by extension, our friends and family – must also be good for all. To some extent, this idea is also just as true. As long as we stay in the world of us as individual creatures, we can come to the conclusion that the process that causes what we define as cancer is bad for us all, as individuals, and therefore it must be a disease. This is because if, as individuals, we can all find a way to figure out how not to die from it, we will all be better off. This is an appropriate and logical conclusion based on the scale of our question.
Unfortunately, there is another scale of consideration. One that we seldom, if ever, consider. This scale is decidedly larger than ours. This scale begins above the benefit for the individual and any collection of individuals and rises to what is actually good or bad for us as a species. This also is not just a simple measure of how things affect the species today but, how the decisions we make will also affect the species many generations from now!
Which brings us to the question of what is a disease and, if what we call cancer is really a disease. The few brave and bold souls who have peeked around that distant corner are now wondering if cancer is simply one potential outcome from a necessary and vital process – a core component of natural selection. They wonder if the mechanism that causes cancer is a natural part of the engine that causes both death and evolutionary adaptation.
While disease and death are bad for us as individuals – and by extension for our friends and families – it is often a very good thing for our survival as a species. Death, and to a lesser extent disease, is the ultimate selection system for improvements in species viability – species robustness. When selection pressures, like susceptibility to diseases have been artificially set-aside through biochemical means like antibiotics and drugs, the individuals who would have died or been significantly harmed, continue to thrive and reproduce. In doing so, they are passing on the traits for the same susceptibilities of disease, and increasing the dependence on the artificial means required to fight off the natural selection process. In effect, we become more dependent on technology and artificial methods to stay alive. The collective species becomes less viable, less robust.
The more people that don’t die, the less robust we are because those who were susceptible to the disease did not get cancelled out. This is a very hard thing to consider and the tendency is to just argue it all away. But, it is a real issue and there is more than enough evidence that it has been happening to us for at least hundreds of years. Today, we have dozens of hyper-resistant bacteria where we no longer have any effective biochemical treatment options. We have numerous illnesses we thought cured that are once again rearing there predatory heads and beginning to become problematic. We are also finding that a number of historical treatments, we once thought quite effective, have been delivering unexpected and unwanted side effects to us later in life.
It is likely that cancer, is not a disease per se, it may be more a natural process of mutation that often can cause death but in some cases provides beneficial changes that make us more robust. And, for a number of reasons, some already stated, while death is always a bad thing for an individual creature, it may not be a bad thing for the species at large.
What’s wrong with living longer?
Against the backdrop of the preceding discussion, we need to look at the effect of a significantly aging population on our healthcare system and the underlying healthcare costs. 60-70 years ago, much less money, time and resources were allocated to treating the diseases we now understand are associated with old age. In the 1870s, when my grandfather was born, the life expectancy for his generation was about 48 years old. He, and many like him, actually lived into their 90s, yet, many also died at birth, in their early years, and into young adulthood from accident and disease – particularly from infections.
The population did not see as high an incidence of many of the diseases that cost us the most today. We have successfully converted many of the fatal conditions of old into the chronic, and often very expensive, diseases of today. Then, people that were susceptible to infection and disease earlier died and many fewer were able to live to reproduce. In effect, those that died were selected out of the gene pool. Those that survived were more robust – less likely to succumb to the disease or infection. Due to modern medicine, technology, and biochemical advances from Pharma and Biotech, we are now able to survive these selection pressures – diseases – and reproduce. As a result our children now have a much higher incidence of susceptibility to these infections and diseases and we require a much higher application of medications and therapies to continue to survive.
Since we are now not dying, we are living longer and as such we are experiencing an exponential growth in the cost of care to keep us alive. As we are aging beyond the historical median life span for humans, of 45 years old, the cost of this extended survival is rapidly increasing. As we age, the natural mechanisms to check the population of the human species – diseases – increase in number and duration. Cancer, dementia, cardiovascular disease and many other age related conditions are just as likely better to be perceived as mechanisms of natural selection and population control than as diseases or anything else.
If it’s about individual survival, why should we consider cost?
This is a great question, and would have been a good one to ask in perhaps 1945. Today, while the need for survival may be individual in nature, we long ago decided the cost of survival must be, at least in part, born by the community at large, in our case the nation. The effect on our pocketbook has been significant. While in 1872 people lived for 48 years on average, today we are living about 78 years. In 1872 a person spent relatively little on healthcare and that which was spent was spread relatively equally throughout their lives.
Today, 85 percent of our total lifetime healthcare expenditures will come in the last five years of life. The average numbers are staggering. For a person born today, from birth thru the age of 73, they will spend about $100,000 on healthcare. In the last five years of their life, assuming they die at 78, they will spend 5 times that amount or $500,000. As we continue to extend life, each additional year is adding massively to the end of life weighted cost. Much of our spending for healthcare is also now weighted heavily to treatments and therapies that are for improvements to our Quality of Life, not our basic survival.
We soon will face a difficult and emotionally filled discussion and decision. If most of what we treat in old age are things we characterize as diseases, but are really the result of naturally occurring processes and species control systems, then it is likely the long term costs will be innately unsustainable. If we could find cost effective genetic methods to improve the species – assuming we will find the will to affect the changes to the genome – then there may at least be a smaller cost curve in our future. But these are both big ifs!
Regardless, in the short run, we will see continual increases in the unsustainable level of healthcare costs. We can change how we consider what is included in healthcare, we can lower our expectations and we can alter what we believe should be covered between the healthcare we actually need and the healthcare options we want. If we are willing to do this, we can buy some time to discover more about how things actually work – the science, we can develop more mechanisms to treat the symptoms – technologies and we can make a determination when direct manipulation of the genome is appropriate. If we continue on our current path, healthcare costs will consume our economy. This is a mathematical certainty.
In order to solve for these problems, we must develop an integrated solution that provides the necessary system architecture and systemic controls to address our needs for care and our wants for care separately. We need a system that begins to provide real accountability for the cost and efficacy of care we receive from providers. We need a system that helps inform us as to the real value and results we should expect from the healthcare providers we select. And, we need a system that effectively manages our own choices between the care we need and the care we want; and, the system needs to work in a totally transparent manner to prevent cost shifting from the needs side to the wants side hiding the real cost.
We need to recognize the cost that our instinct for individual survival, combined with our own ingenuity, science and technology is having on us as a species and more immediately perhaps, as a nation. The referenced Whitepaper presents a series of solutions that help to address these issues. The proposed solutions break our healthcare system into two markets characterized between the basic LifeCare we need for all and the optional Quality of Life Care we want for those that make the life choices to obtain it.
LifeCare is constructed to provide the care that everyone needs to survive, thrive and be productive. LifeCare is constructed to assure affordability, access, fairness, efficacy, accountability, price certainty, transparency and transportability. No networks, no deductibles, and no co-pays are needed to assure affordability, efficacy and access. The innate approach also preserves the option for choice. Choice based services are delivered through the Quality of Life Care market. This market driven system provides the variety and value based services that people want.
Both market driven systems are tightly integrated through a single point of administration providing full easy access, comparison, and assistance. This same single point of administration provides the integration of care between the various facilitators, providers and payers with full coordination of care and benefits to the individual user – called participants – across all available sources. This assures that if there are alternate sources of care and funding available, everyone in the participants virtual care group is both aware of it and able to coordinate their activities to assure the best outcome. And, as an additional benefit, this approach should be able to reduce the national healthcare spend by between thirty and forty cents on the dollar.
(Thomas W. Loker is a contributor to California Political Review.)