Some Utopian Thinking on Health (Part II)
In the first post I talked about the need for a more idealistic health policy than one which relies so heavily upon the pharmaceutical industry, leading to the question of how we arrived at our current situation. I will address that question now, and part III I’ll have a go at suggesting some practical steps that might be taken to improve things.
The thing is, pharmacy used to be pretty miraculous. Type I diabetes was a death sentence before the discovery of insulin (1922). Trivial infections killed millions before penicillin (1929) and asthma regularly killed children before salbutamol (1968). Each of these discoveries has saved many millions of young and healthy lives, however this golden age of discovery could not continue indefinitely. The low-hanging fruit was gone by the nineties, and time was running out on the most profitable patents – but a private company must run fast just to stay still. Shareholders demanded further ‘miracles’ in an age of largely prosaic science, which is basically why the American pharmaceutical industry now spends more on marketing than it does on research. This is as good an example as there is of why private sector competition does not automatically lead to net efficiency.
(At this point I had a look at the list of winners of the Nobel prize for medicine, hoping to show that the discoveries I use every day at work date mostly from the middle of the century, and that more recent advances are of more theoretical benefit. This prediction more or less stands up, but to be honest the more striking findings are as follows; 1.The committee gave the prize to the inventor of the lobotomy in 1949 (!), 2. 1970’s winner would appear to be a pirate; a first for this proud race.)
The problem is that most researchers are paid not to ask themselves, ‘how can I improve human health? Instead they must ask themselves, ‘How can I maximise profit for my company?’ As George Monbiot puts it, talking about why capitalist solutions to climate change are intrinsically flawed, ‘the only thing they can’t sell you is less.’
This lead to various phenomena, none of them good, such as the wave of ‘me too’ drugs, which were generally small tweaks to successful old medications whose patent had expired, marketed heavily on what was often pretty thin evidence of any improvement. Basically, the manufacturers would adjust the structure of a chosen drug to produce something that was very similar in efficacy, they would then test it with reference to every side-effect they could think of, and inevitably it will be marginally better in some area or other.
They would then choose that one fairly fuzzy end point and market it agressively at a high price without mentioning any areas in which they’d discovered that it is in fact, worse. As with all scientific critique, the point is best illustrated by reference to XKCD.
At the same time much has been made of the theoretical potential for ultra high-tech therapies based upon genes or stem cells, though both remain some distance from producing many practical applications at this stage. I am a scientist, and I’m all for the work upon these frontiers continuing – however I’m also a leftist, and the knowledge that this research is happening in a world that has so profoundly failed to stop children dying from diarrhoea is deeply unsettling. I have the same mixed feelings about widely reported idea that theoretically, stem cells might one day allow the creation of new organs for those who have been afflicted by cancer. Wonderful as that prospect is, it seems gratuitously technological when we haven’t yet done the simple things as regards prevention.
Around a hundred years ago an Irish doctor called Robert McCarrison was working in the Hunza valley in northern Pakistan. In ten years, in a population of 8000 people, he did not see a single case of a gastro-intestinal cancer, and in writing about this he makes a strong case that their pre-industrial diet and lifestyle is the reason why they are so free of these problems, nor are his broad findings considered controversial. That is about as close as humankind is ever going to get to a single unified ‘cure for cancer’. Implementing radical public health policies based on that knowledge would be inexpensive, green and egalitarian, however as it involves no readily saleable product it is not something that the free market will ever do spontaneously, and thus it has not yet been done.
Obviously I’m not arguing that pharmaceutical research should stop altogether – merely that the current model in which research is dominated by Pfizer et al has probably taken us almost as far as it’s going to. If, on the other hand, we could successfully decouple the need for private profit from the research process, non-pharmaceutical research priorities would spring into life, and such research into medicines as continued would be free to focus on the diseases of the Global South – for having been of little commercial significance previously, there is a better chance of miracle-drugs still waiting to be found in these areas.
This would not be universally popular; people like taking pills, and doctors like handing them out. Whilst doing GP work, I often felt great pressure to prescribe medicine at the end of a consultation in order for both myself and the patient to feel like I had done something tangible, even when I didn’t feel that a medicine was indicated. Similarly in A+E I must have seen hundereds of kids with viral infections who’d been given antibiotics by their GP, which unsurprisingly hadn’t done any good. The idea of a simple, instant, magic chemical solution to cure any human ailment it very appealing – as it requires no difficult change on the part of the patient, nor any consideration of the wider factors behind human illness. This is regrettable as it is in this consideration that many of the breakthroughs of the future lie.