Sunday, January 22, 2006

Medical Costs of the Future...Lower and Lower

The following is an esay from a book I co-authored in 2000 on the impact of technology on future life (Critial Mass, MC2 Publishers, 2000).
This particular essay is on how I and my writing partner came to feel that medical costs would peak, then fall during the 21st century.

Computers and Medicine: Hippocratic Art becomes Marketing Artifice

People of our generation (so called Baby Boomers) were raised to believe several things about doctors and medicine. First, doctors were members of some sort of priesthood. They knew things we could never know. They had education above and beyond that of normal people. We were encouraged to believe that doctors knew what was best for us and knew things about us we could never know.

Second, medical knowledge was the hidden knowledge of the inner sanctum, the runes of health often cast in terms the average person could not even begin to decipher. Body parts, diseases, conditions, bacteria, and viruses were named in Latin or Greek and often seemed deliberately obtuse. We were not meant to read the prescriptions scrawled by our doctors, or to ask too many questions.

Third, they gave you a sucker if you were a good patient.

The attitude is changing, though. Rising medical costs, coupled with a new understanding of disease and health is changing perceptions about the world of medicine. The cost of medical treatment rises at about 3 to 5 times the rate of inflation. Nothing seems to reduce it. Hospitals have tried to rein in costs. Their ideas, from reducing staff and shortening stays to timesharing equipment among facilities do not keep pace. In desperation, hospitals form conglomerates and try to become managed care associations, which tends to reduce the service to their patients while failing to contain costs. Managed care tries to rein in doctor fees, but the cost in care quality is high. They even stop giving away the suckers.

Finally, they try marketing. It begins to work, but in unforeseen ways.

We have a national (perhaps cultural) taboo against marketing medicine. We don’t like our doctors hawking cures to people so desperate they’ll try anything. We used to see it; we called it Patent Medicine and it earned a well-deserved reputation for deception and danger. When anyone could set up shop on a street corner and sing the praises of assorted elixirs to cure everything from smallpox to social diseases the population was at risk and had no recourse when the so-called cures failed. As a nation, we stepped in and began to regulate medicine and drugs as a way to protect ourselves from the charlatans along the road.

Yet, we have found ways to market prescription medicine and even medical care again. We see commercials about new medicines (carefully avoiding any statement of what they treat) and we see billboards from hospitals regarding the level of obstetric and neo-natal and cardiac care they provide (again, carefully couched to avoid any claims or any discussion of costs). Every sports magazine, women’s magazine and health magazine on the newsstand carries at least a few full page advertisements form prescription medicine, complete with information about uses and side effects that used to be available only to doctors.

We see it because our perception of medicine has changed. The only effective and ethical way to mass-market medicine was to make it more approachable, more understandable. It became necessary to involve patients in their own care to keep costs down. To do that some of the mysticism had to move aside.

Concomitant with the public’s increasing awareness of health and medical issues, computer technology made it possible to consumerize many aspects of medicine. Blood pressure machines began appearing in stores. Electronic thermometers and blood sugar monitors emerged as over the counter devices. Even digital stethoscopes are available to the causal buyer.
While medicine is becoming more approachable and understandable, we still want more. So, what other role does high technology, particularly information technology, play in this move to consumerize medicine?

Start with the hugely expensive MRI and CAT machines. We see amazing images produced by these non-invasive scanners. We can see the Visible Man Project, which available for anyone to see via the Internet, but only possible with computed tomography. Otherwise you would just have thousands of flat photos looking like sliced liver. Because of computed tomography, you can see a three dimensional image that can be rotated in all three axes and zoomed or probed with virtual views. We see TV shows like The Operation with incredibly high tech medical gear. Microsurgery, aided by motion control computers like those used in cinema, allows surgeons to perform absolute miracles.

These devices, while deeply dependent on computer technology, are only the beginning. They are large, complex, and may require a new priesthood of computer-savvy technicians. In addition, they require trained analysts to read the results. What if that were not so?
For centuries, medicine has been viewed as more of an art than a science. Hippocrates’ famous oath, in fact, describes medicine as an art, not a science. The original oath (circa 300 BCE) required young doctors to care for their teachers and teachers’ families and to teach other doctors at no cost. That was probably the first clause to go. It also prohibited surgery (leaving that to the barbers of the time as they had the blades) and abortion. The AMA has changed the original oath just a bit.

Despite the changes in the oath, medicine remains as much art as science. Or, at best, a science in the service of an art.

For example:
Diagnosticians follow complex and intuitive chains of reasoning. Chains they are often at a loss to explain. Arriving at the correct diagnosis in the shortest possible series of steps is still considered one of medicine’s finest skills and students are tested in it constantly. It is obviously important to diagnose the correct problem in the minimum of time since a failure to do so can leave someone very dead. Some doctors have an almost mystical skill at this and they command very high respect in their profession.

Surgeons constantly talk about the delicacy of their operations. “The hands of a surgeon” is a phrase that captures the shamanistic nature of the awe in which surgeons are often held.
And, of course, the old joke goes that you and I, when confronted with a perplexing but solvable problem in our area of expertise, say that, after all, “it’s not rocket science!”

Rocket scientists say, “it’s not brain surgery!”

Brain surgeons say, “actually, it is brain surgery!”

Theirs, it is believed, is the most complicated and delicate of the surgeon’s art. Typical neurosurgeons know this too. They know it all too well. Very big heads in neurosurgery.
Understandable, really. But, perhaps, on the edge of changing.

The advent of the computer has begun a change in this view of medicine. With tremendous amounts of computing power available it is possible to better image the interior of humans and to better simulate the reactions taking place there. Art implies a certain lack of certainty and precision; science implies the opposite. The art of medicine is finally becoming a true science of medicine as our understanding of biochemistry matures. It matures because we can visualize molecules and simulate reactions using computers.

Let us look at a few examples.
Pharmaceutical companies have always referred to their discovery of drugs because of the brute force approach used throughout that industry. The process is changing, however, and now they refer to a drug and its design. Pharmaceutical companies now seek to design molecules, not discover drugs, because we now understand health and disease as macro-level manifestations of molecular processes. To get to this point they have employed information technology at its highest level.

Visualization on computers now allows researchers to see biological processes in simulation. Incredibly complex mathematics used to derive and predict the chemical forces that bind, shape, attract, and repel one organic molecule from another are available as 3D models. Virtual reality with force feedback allows designers to feel those forces as they pick up, twist, bend, and shape chemical compounds into novel and useful forms.

Animal testing moves into the past as our drugs become so tailored to the human condition that the only way to accurately assess their efficacy, other than with human trials, is to simulate their reactions in a human body. Animal models are still great for many purposes, but we can already see the writing on the wall. With the focus now on a genetic basis for disease it will no longer be as useful to test a drug on a rat, a rabbit, or even a chimp. The new class of pharmaceuticals that will emerge in the next few decades will be computer generated and so tailored to humans that animal testing will be useless.

Classic biology has left the realm of the taxonomic and descended to the garage level of the mechanic. Over the last two decades, aided by information technology, biology has begun to finally flourish as a predictive and engineered science. More and more high school biology classes are dissecting frogs virtually rather than using real frogs. Technology created for the film industry to show the subtle changes of a body as it disappears has been re-targeted for use in medical schools to replace the dissection of human cadavers.

Practical medicine is becoming more mechanistic as we unlock the molecular basis of disease, reproduction, and life. As it becomes more mechanistic, it becomes more amenable to being reflected in cyberspace. That is, as our understanding of our physiology drills down toward the lowest molecular nature of life, the information becomes more amenable to digitization. Once digitized, the information that describes the processes that make us ill or make us well can be recognized, manipulated, and administered by computers in far more precise ways than possible today.

Medicine will continue, for a while, to increase in cost. Pharmaceuticals will be costly to develop and the intellectual property represented by them will be hotly protected. But, not for long.
When the computer simulations become accurate enough and when the processes are understood well enough, you will begin to see the movement of medical treatment out of the hospital, outpatient surgery center and doctor’s office to Wal-Mart. You will begin to see computer kiosks that use expert systems to diagnose symptoms described by the customer. Note we said customer, not patient. At this level, you cease being a patient (that has always seemed an interesting term) and become a consumer and customer.

The psychology of taking your medical advice from a machine is considerably different that that of taking such advice from a human practitioner. The writer Larry Niven has referred to autodocs in many of his stories and novels. These are machines you slide into which perform examinations, diagnosis, and finally treatment. Not unlike the booth at the Levi’s shop that measures you for custom made jeans.

We may be a while before we have whole-body autodocs, but you can expect that computerization of medicine will migrate treatment for many ailments into kiosks, into your home and into the mass market. Who needs a pharmacist when a computer can take the prescription and synthesize the molecules needed (the medicine) and dispense directly to you? Who needs a doctor when a computer can take the history, perform the tests, diagnose the ailment, and write the prescription?

Who needs either of them when this can be performed at home? For example, a toilet which will perform many chemical tests on your urine and feces is being developed. The analysis of our eliminations has a long and proud history in medicine (short of surgery, how else could a doctor get anything out of you that had been through the loop, so to speak? Former food was convenient.). Such a toilet will be able to analyze and diagnose a wide variety of conditions. It will recommend treatment, which may be automatically included in your next grocery order since your refrigerator will talk to your toilet.

There is little reason to think that automated treatment is out of the question. Antibiotics could be administered by your bed linens while you sleep or by your clothing the next day. Antibacterial fabric is already a reality. Antibiotic fabric is not too far behind. Nicotine and arthritis patches have made it quite acceptable to have medication dispensed to you through skin absorption.

Our understanding of the effects of particular molecules is increasing steadily. With appropriate analysis of the customer (at the DNA level) and with sufficient computing power it will be possible to have a pharmaceutical synthesizer in your home to catalyze and synthesize molecules tailored to you and your condition. Security is a consideration, but it will be much harder to get an autodoc to dispense unneeded barbiturates or amphetamines than it is to corrupt a human doctor.

A while back Bill had Lasik surgery to improve his eyes. The procedure was painless, quick, and almost completely controlled by computer. It is not too hard to imagine that, in a few years, a machine at a Sears would be available to perform a similar surgery sans ophthalmologist. The necessary computer system to measure, calculate, track and focus a laser to perform such an operation is not beyond imagination at all.

It is not hard to imagine how other forms of simple surgery can be computerized and consumerized. Almost any skin surgery could be done with special lasers and software. Wart, mole, and cyst removal, Melanoma diagnosis, even some liposuction and vein stripping could be made fully safe, cheap, and computerized. Non-invasive surgical techniques will continue to improve with the growing sophistication of computer targeted and focused ultrasound, x-ray, microwave, and other forms of energy.

An elegant solution to bacterial infections is the possibility of using bacteriophages instead of antibiotics. These are viruses which are parasites of bacteria. Specific phages attack specific bacteria. Once the bacteria are dead, the phages die off. The two organisms evolved in twain with each other and bacteria are not likely to develop immunities to phages. They have already adapted as much as necessary. The phage for a particular strain of bacteria is typically found with the bacteria. In the human being, this is usually in the feces.

A computerized toilet could recognize particular disease bacteria, then isolate and amplify the phage associated with that bacteria. The toilet could then insert, inject, or transduce the phage back into the human through injections or patches.

This would form an extremely elegant solution to certain common bacterial infections where today we use broad spectrum antibiotics that prompt many bacteria to form resistant strains. The bacteria die and the phages then die off as well. The intelligent toilet is needed to make it work.

The result is that, in the not too distant future, medicine will become cheap. Sure, we will need controls to make it safe and effective. There will be failures and there will be quackery, but there is a lot of that out there now. We have to move forward to improve medical care, and we can do this if the specialized knowledge of doctors is captured and digitized, the specialized facilities of pharmaceutical companies are miniaturized and digitized, and there is a growing demand for cheaper care.

The driving forces are technological innovation, synthesis miniaturization, and computer control of those processes. The computer control issue is well in hand. Much of the synthesis technology we can take from NASA robot analysis technology on Mars probes. Nanotechnological advances will make chemical factories small and cheap. Research into all of these is in high swing now and we can expect dramatic developments in the future. We can also expect strong resistance.
Pharmaceutical companies are entrenched. Doctors are entrenched. Pharmacists are entrenched. They will all resist as will the public at first. Until the bills roll in.

Where will autodocs catch on first? Probably in third world countries that can’t afford medical care today, much less in the future if the costs keep rising. Provide a village with a device that can accurately diagnose and treat a variety of ailments and injuries for virtually free and third world governments will adopt it with a vengeance. Automated medicine could save millions in developing nations.

Second world nations who are struggling under the effects of brain drains from the cold war will probably adopt it next (they may even be a major part of the development). China, North Korea, and Russia are prime candidates who have or can have the technological skill to develop automated medicine and the lack of skilled practitioners of traditional medicine to prompt a demand.

Ultimately, as our own groaning medical system reaches the limit of its abilities to cope with an aging boomer population (aging into its hundred and twenties because of advances in traditional medicine), we will adopt it here as well. We’ll demand it.
What of the concern that pharmaceutical companies will still be needed to manufacture and distribute the medicines and might still charge inflated prices for them? Pharmaceutical companies rely on intellectual property rights. The molecules they produce and the processes they use to produce them are the secrets they hold dear. But the ability of computer-controlled nanotechnology to manipulate individual atoms into molecular combinations on demand will make those secrets very fleeting.

Once the processes are automated at the atomic or molecular level (rather than the macro reagent level they operate at now) there will be almost nothing to stop any particular drug being taken apart and then re-assembled. Slight, irrelevant changes in the molecule may be the way small firms get around patent issues. Some, in remote seriously ill corners of the globe, will just copy the drug and licenses be damned.

Think of it. Even now, if any village in South Africa (with 10% of its population HIV positive) could synthesize as much AZT as it needed on demand, would patent rights stop them? Not likely.

Sound outrageous? Consider the following:
Cloning of Dolly the sheep (and now many other animals) was accomplished by using delicate but well understood and very replicable techniques. The key turned out to be the application of a minute amount of electricity at just the right point in the process. It is all documented and the equipment and chemicals needed are available and not expensive. Farmers are already looking into it.

DNA strands can now be analyzed by computer circuitry using a special chip that has DNA molecules attached to silicon transistors on the chip. Such a device will soon be used routinely to analyze samples for infections. A home model is already planned.
Scientific American recently published a method by which amateur scientists could invoke the Polymerase Chain Reaction (PCR) in their homes. PCR is a process used in genetic research for rapidly reproducing DNA segments into quantities sufficient for analysis and use. It was invented a few years ago and made DNA research tremendously more effective by reducing the wait times for DNA reactions by factors of thousands. Now, you can do this in your kitchen.

We talk about high-tech medicine in this country all the time, but we’ve seen nothing yet. Most medicine is still the purview of doctors who listen to patients, make an educated guess of the problem, perform a test or two confirm the hypothesis and write a prescription. The “perform a test or two” step is so seriously discouraged by HMO’s and Managed Care insurance (and by National Health in other countries) it is often skipped. None of that is difficult to automate.
When it comes to hospital care, we need to be careful about assuming too much regarding its importance. Most people do not want medical care in hospitals. They tolerate it when nothing else will do. Much hospital care is devoted to easing discomfort in lieu of anything else to be done. People accept that because the discomfort is distracting and depressing.
What people want is medical repair. They want the problem to be corrected and to get on with their lives. Yes, we do want the quick fix. But, if the quick fix actually is a quick fix and the problem actually is corrected, what’s the problem? Influenza used to send millions to their beds and hundreds of thousands to their graves. Now it is a minor annoyance for most in this country.
So, while hospice care for terminal patients will continue in those situations we cannot correct (and there will be many), do not expect people to complain too much about not having hospitals to take care of them when a quick trip to KMart for their cancer cure or to Target for their cardiac repair kit will get them back on track with their life. Automated medicine will offer that.
Medicine and medical care will become very cheap in the future because both are highly amenable to technological innovation and computerization. It is at exactly this intimate level that cyberspace’s digital reflection of our society will be at its sharpest.

This essay is copyright Bill McDaniel and Pat McGrew...used with permission

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