We didn’t deliberately set out to slam the US in this review of policy-related media reports from the past six or so months. It is just how the cards were dealt. In the past year or so, evidence has been mounting that far from having the oft-touted “best healthcare in the world,” Americans have one of the worst, as the following sampling of reports shows.

The rate at which infants die in the United States has dropped substantially over the past half-century, but the United States ranks near the bottom for infant survival rates among modernized nations, ahead of only Latvia, and tied with Hungary, Malta, Poland and Slovakia. And despite having more neonatologists and newborn intensive care beds per person than Australia, Canada and the United Kingdom, the United States still managed to achieve a higher rate of infant mortality than any of them.

As well, the prevalence of major disease is much higher among Americans over 50 than among their European peers. Examples:

• Arthritis: More than twice as high
• Cancer: More than twice as high
• Heart disease: Nearly twice as high
• Obesity: Nearly twice as high
• Diabetes: 16 percent of American seniors vs. 11 percent of European seniors

The higher rate for cancer could be due to more intensive screening in the US, but higher rates of obesity-related diseases and conditions (such as high blood pressure) suggest Americans really are sicker.

The US spends about twice as much per capita on healthcare as the Netherlands, Germany, and France. If America could achieve European rates for 10 common chronic conditions among the elderly, it would save between US$100 billion to $150 billion a year.

Disease prevention and better disease management would be more productive policy objectives than the preoccupation with who pays for what. But the United States ranks last among 19 industrialized countries for deaths that could have been prevented by access to timely and effective healthcare. These deaths declined by an average of 16 percent in the 18 other countries, but by only 4 percent the US. If the US had performed as well as the top three countries (France, Japan, and Australia), it would have had 101,000 fewer annual deaths.

A 2007 survey comparing adult healthcare experiences in seven countries — Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States — found that the United States “stands out” for cost-related access barriers and less-efficient care . Despite “by far the highest share of national income [spent] on health care,” an estimated one-third of US adults were either uninsured during the year or underinsured.

China Nearing Tipping Point as Biotech Powerhouse

America’s prowess in biotechnology is also in decline relative to other countries. Take China, for example: A study published in Nature Biotechnology in January indicates that the Chinese government’s efforts to promote its biotech industry are working, and will probably work even better as friction points are smoothed out. The friction points slowing things down include risky investment conditions, such as slow-moving policy and regulatory processes, an uncertain financial system, rigid restrictions on the export of capital, and mistrust of the Chinese government’s intentions with regard to intellectual property rights protection. These issues notwithstanding, there is now a “brain gain” as talented Chinese scientists and entrepreneurs return from abroad, and as Overseas Chinese establish transnational companies with a presence in both China and the West.

Examples of progress in the Chinese industry include:

• Beijing Wantai Biological Pharmacy Enterprise has developed and marketed a large range of blood screening tests for HIV, hepatitis B and C, sexually transmitted diseases, rotavirus, and other diseases.
• Shanghai Huaguan Biochip Co. exports a range of fertility tests and formulations for HIV, tuberculosis, hepatitis C, and STDs to Asia, Africa, and South America.
• Shenzhen SiBiono GeneTech Co. developed the first commercialized gene therapy product approved anywhere in the world, Gendicine, to treat head and neck cancers. More than 5,000 patients have been treated with Gendicine, about 400 of them from overseas. The drug is currently undergoing further clinical trials in China for several new indications, including liver, abdominal and pancreatic cancer.
• Beike Biotechnologies has a network of satellite hospitals, clinicians, and research laboratories to commercialize stem cell therapies for Alzheimer’s, autism, brain trauma, cerebral palsy, diabetic foot arteriosclerosis, and spinal cord injury. Beike has treated more than 1,000 patients, including 60 foreigners. Apparently, China’s Food and Drug Administration does not require clinical trials of these therapies, so it is difficult to evaluate their safety and efficacy.
• Shanghai Genomics is developing novel non-steroidal anti-inflammatory therapeutics to replace currently available treatments for inflammation and fibrosis of the liver. Its first product to reach the market, GuBang, is a material for bone void filling that can aid bone growth and serve the growing needs of Asia’s aging citizens.
• Shanghai United Cell Biotech manufactures and markets one of only two oral cholera vaccines (and the only one available in tablet form) available worldwide.
• Other Chinese biotech firms are working on an oral HIV vaccine and novel vaccines against Japanese Encephalitis, SARS, and pandemic avian influenza (H5N1).

Science vs. Religion

The US has its own friction points to smooth out with regard especially, but not exclusively, to its biotechnology industry. A panelist at the US National Academy of Sciences told reporters at the launch of a book on evolution that he would worry that a president who did not accept the theory of evolution— such as Mike Huckabee, who at the time of writing has dropped out of the 2008 presidential race but is being touted in the press as a potential running mate to John McCain — would “lead our country to ruin.” Huckabee is among the staggering 47 percent of Americans who, polls show, do not believe in evolution. So, apparently, is President George W. Bush, who has said he supports teaching “intelligent design” creationism to American students.

It is ironic that biotechnology is forging ahead with intelligent design of its own. The UK’s Human Fertilisation and Embryology Authority has licensed scientists at King’s College London and Newcastle University to create human-animal embryos for researchinto life-threatening diseases, following public consultation showing Britons are “at ease” with the idea. The scientists will use stem cells derived from these chimeras to study Alzheimer’s disease, spinal muscular atrophy, and Parkinson’s disease, as well as to understand how stem cells develop into different tissues in the body.

Perhaps the American public’s doubts about evolutionary science explain why only 40 percent of a recent survey of parents thought that children should be tested for gene mutationsthat predispose them to breast or ovarian cancer, and why a majority of professional groups recommend against the genetic testing of minors in the absence of known medical benefit. Such beliefs and such policies may not hold up over time: the survey findings suggested that the next generation, having grown up with genetics, may be more comfortable with genetic testing. And, we would add, they’ll be inundated with ads selling them China-made DIY genetic test kits over the Internet.

Boom Cost Miscalculated

Contributing to the abysmal grades our policymakers are earning in managing healthcare for Americans is a November 2007 US Congressional Budget Office (CBO) report on “The Long-Term Outlook for Health Care Spending.” The reports says that policymakers have overstated the projected impact of population aging and the impending retirement of the baby boom, and concludes that population aging will have only “a modest effect not only on national health care spending but also on federal spending on Medicare and Medicaid.” How modest? — about 2 percent as a share of GDP for Medicare and Medicaid spending. Excess cost growth, on the other hand, would increase that spending by 10-12 percent. The Medicare Trustees estimate assumes, in contrast, long-term excess cost growth in Medicare of only 1 percent.

Could it be that the overemphasis on aging deflects policymaker focus away from unsustainable spending, where focus is more clearly merited? One commentator points out that “excess cost growth” to the CBO is “revenue and profit growth” to the US healthcare industry. “European health systems have addressed these issues for the past 30 years, while the US health system has engaged on a technological spending spree fueled in part by unconstrained prices.”

We have argued before that technology per se is not the big cost driver (although we may have to revise that opinion if proton-carbon beam therapy becomes de rigueur – see below.) After all, Europe uses the same scanners and drugs and robots. But it manages them through a regulated market, not the increasingly less fettered market understandably preferred, and successfully lobbied for, by an industry focused on revenue and profit growth rather than on the US patient’s or the US national interest.

An example is America’s tolerance of direct-to-consumer marketing by device makers: Late last year, Cordis Corporation mounted a marketing campaign to sell its Cypher drug-eluting stent directly to consumers. Critics contend that stents are being implanted too often in patients who might do better with other treatments. “It’s deplorable,” said one.

Another example: There are about 900 genetic tests available, a Detroit News articlesays. A US Department of Health and Human Services draft report released in November called for increased regulation of genetic testing after finding “significant gaps in regulation.” It called on the government and private businesses to work together.” (Hmm. Isn’t that the problem? That they already are?)

A better – regulated – way than advertising to inform patients was proposed in January by the US Institute of Medicine. It recommends that Congress establish a single national resource of health information, with the goal of telling patients and doctors what is known about the effectiveness of a drug or treatment, and what is not, in “a standardized, objective fashion that will be considered reliable and trustworthy by all decision makers.” The IoM said spending on ineffective treatments adds to healthcare costs, and that consumers are asked to make better and more economical choices on the basis of piles of conflicting and confusing data. It recommends a federally mandated program that evaluates clinical services, conducts systematic reviews of research studies, and establishes clinical practice standards and guidelines.

“We know that policy makers, clinicians and patients are clamoring for this kind of information power,” said a spokesman for the Robert Wood Johnson Foundation, which funded the report. Do we? Let’s see what Congress does with the recommendation, first.

Managing Accelerating Innovation

To be fair to policymakers, they are just as subject to the same stresses from our favorite topic – the acceleration of innovation – as everyone else. The speed with which medical innovations are adopted depends not just on them but also, inter-alia, on biomedical research, regulatory approval processes, and third-party payers’ decisions to pay for new therapies. But the people and institutions in those three communities read different journals, attend different meetings, and speak different professional languages. As a result, there is an “intellectual chasm … between those who do innovative research and those who deliver it,” according to the journal Health Affairs. Given the growth of what we at the Digest call postmodern medicine, and given the scope and urgency of the healthcare cost and financing issue, “The moment to create a powerful new dialogue among these separate but mutually dependent communities could not be more propitious.”

“Set Proton Beams to ‘Stun,’ Scottie”

A proton beam therapy center — a 222-ton accelerator housed in a building the size of a football field with walls up to 18 feet thick — costs well above US$100 million. It is “the world’s most expensive and complex medical device,” and since 2000, the United States has acquired five of them. (Before succumbing to shock and awe, remember that funds diverted from a single stealth bomber would pay for twice that many proton centers, though the bomber would have undeniably more bang for the billion bucks.)

But with dozens more proton centers under construction and in planning, shock and awe is the order of the day. One costing more than $140 million is being built by Hampton University in Virginia, a small college that does not even have a medical school. Two proton centers are planned for Oklahoma City, and two for Chicago.

Supporters argue that existing centers collectively can treat only several thousand patients a year, and seem to suggest that 250,000 Americans could benefit from protons, keeping more than 100 centers busy. There are no solid clinical data that protons are better than the latest intensity-modulated radiation therapy, but if you or your child has cancer, you will probably opt for protons given a choice.

Over time, costs should come down — one company has received several orders for a $20 million proton machine – unless something even sexier pops up. And it has: A therapy using beams of carbon ions, said to be even more powerful than protons. Touro University says it will build a combined proton and carbon therapy center outside San Francisco, to open as early as 2011. The Mayo Clinic is also seriously considering one. At about $300 million, these machines are approaching stealth bomber range.

If ever there was a justification for certificate of need, perhaps proton/carbon beam machines are it.