While one healthcare megatrend—toward self care—appears to be starting to bite at hospitals’ financial prospects, another is gearing up in the wings: At least one journalist and newspaper have got the message about the impending robotic revolution’s impact on jobs and therefore on society. The question is, will policymakers get the message, and will they do anything about it?

Even Federal Reserve chairman Alan Greenspan appears not to take into account the impact of emerging technologies in his long-term predictions for the economy in general and for Social Security and Medicare in particular. However, he does seem to acknowledge the possibility of imminent and “painful adjustments” in public programs.

The trend to self-care will increasingly put patients more directly in touch, and therefore in possible conflict, with drug and medical device makers, yet the current US administration (which appears to promote self-care) is attempting to block legal redress to consumers against drug and device manufacturers if the drug/device in question was already FDA-approved. The administration’s arguments might carry more weight if it would act to clean up corruption at the NIH, including the FDA—see for example this story in the June issue—and to stop unduly protecting the pharmaceutical industry (as reported in the August issue). Until corruption and corporate favoritism are rooted out, blocking citizen redress while pushing them into the arms of those corporations seems unfair if not unconscionable. It is ironic that while the administration says it does not want “lay judges and juries” to second-guess FDA experts and deprive patients of potentially beneficial treatments, it is quite happy to second-guess its own experts (as, for example, an expert committee that overwhelmingly recommended approving an emergency contraceptive, and an FDA expert who spoke out about the potentially suicidal effects of antidepressants on children.) And that’s besides the question of who exactly is deciding whether a treatment is beneficial or harmful, if experts, judges, and juries are taken out of the loop.

Expert scientific consensus with regard to the beneficial prospects of stem cell therapies have also been taken out of the loop, as was recently reinforced by Mrs. Bush’s statements in support of her husband’s policy on stem cell research. Meanwhile, California republicans, largely avoiding both ethical and scientific issues, are opposed to state funding of stem cell research on the grounds that the state budget cannot afford it.

The British, on the other hand, have resolved the ethical issues and are forging ahead with a national stem cell bank that will accelerate research while enabling the government to keep a tight rein on it. The British advantage has already lured leading US researchers to move east across the Pond, reversing nearly a century of brain drain. The Brits don’t have it all to themselves, though. Singapore is successfully vying for top talent as well, and seems to have more money to spend on it than they do. The bottom line: unless its relatively unregulated and profit-motivated private sector picks up the slack—to the likely detriment of ethics—the US will lose the race to whatever benefits stem cell research bestows.

India, too, is increasingly a beneficiary of the outsourcing of biotech and pharmaceutical research, as it has been of information technology.

Trends Starting to Bite?

Moody’s Investors Service recently placed a “negative outlook” on the not-for-profit health-care sector, citing declines in reimbursement from insurers, high expenses, and minimal patient volume growth. Most interestingly from our perspective, Moody sees “greater costs being pushed down to the consumer level, resulting in consumers selecting lower-cost options leading to lower hospitalization levels.” Lower-cost options for self-caring patients is perhaps the central trend revealed through Health Futures Digest, and the Moody outlook is a sign that the theme is growing teeth.

Reference: Japsen, Bruce (2004). “Financial prognosis for hospitals slips to “negative,” Moody”s says.” Chicago Tribune, August 19.

The End of Work

“The Luddites,” writes Gregory Lamb in an (as usual) insightful article in the Christian Science Monitor, “had a point: Automation causes unemployment.” We at the Digest have long been at pains to point out, as Lamb does, that if automation is accelerating exponentially (undeniably, it is) then the economic and social implications are staggering. Where we differ from Lamb”s equally nervous expert sources is whether the history of technology”s eventually creating more jobs than it destroys will continue to hold. We don”t think so, absent a recognition of the problem by political leaders and public policymakers.

We also agree with the economist who told Lamb that America (though we would say the mass of the American people) in particular has more to fear from automation than from the outsourcing of jobs overseas.

Among the rapidly disappearing, and in some cases disappeared, jobs:

• Letter carriers (replaced by email)
• Telecommunications workers (some 3-400,000 jobs lost over two decades to automation)
• Counter clerks (stores, banks, airlines, etc.; replaced by kiosks)
• Gas station attendants (replaced by pumps that take credit cards)
• Fast food workers (replaced by automated kiosks)
• IT service workers (replaced by AI systems with voice recognition and speech capabilities)
• Journalists (replaced by AI systems that can research and write routine articles, such as traffic reports and obituaries)

Reference: Lamb, Gregory M. “Coming soon: Robo-greeter.” Christian Science Monitor, August 30.

Greenspan on Social Security, Medicaid Disaster

US Federal Reserve Chairman Alan Greenspan said recently the country will face “abrupt and painful” choices if Congress does not move quickly to trim the Social Security and Medicare benefits that have been promised to the baby boom generation. “If we have promised more than our economy has the ability to deliver, as I fear we may have, we must recalibrate our public programs so that pending retirees have time to adjust through other channels. If we delay, the adjustments could be abrupt and painful.”

What would be recalibrated? Well, suggests Greenspan, perhaps retirement age should be continually adjusted as life expectancies increase. “Though the challenges of prospective increasingly stark choices for the United States seem great, the necessary adjustments will likely be smaller than those required in most other developing countries,” he said, noting that Europe and Japan will have a much higher proportion of retirees to current workers in coming years.

The main difference between the US and Japan may, it seems to us, be that Japanese policymakers and businesses have been alert to the problem for some time.

Reference: Crutsinger, Martin (2004). “Greenspan Cautions on Baby Boomer Benefits.” AP via Yahoo News, August 27.

Administration Removes Consumer Redress

The Bush administration contends that consumers ought not to be able to recover damages for injuries by FDA-approved drugs and medical devices, reports Robert Pear in the New York Times. The Justice Department, he writes, acknowledges that this position reflects a change in policy, and “it has persuaded some judges to accept its arguments” in court.

A US House democrat said the administration had “taken the F.D.A. in a radical new direction, seeking to protect drug companies instead of the public.” In 1997, the government said that FDA approval of a medical device set the minimum standard, and that states could provide “additional protection to consumers.” Now the Bush administration argues that the agency”s approval of a device “sets a ceiling as well as a floor.”

A Public Citizen Litigation Group lawyer said the administration’s new policy amounts to “a backdoor type of “tort reform” that would shield manufacturers from damage suits,” writes Pear. A woman whose husband committed suicide after taking the antidepressant drug Zoloft for five weeks said: ““ it’s ridiculous that the government is filing legal briefs on the side of drug companies when it’s supposed to be protecting the public.” One source alleged that FDA lawyers led by the agency’s chief counsel, Daniel E. Troy (who had a potential conflict of interest, having once represented Pfizer), had “repeatedly interceded in civil suits on behalf of drug and medical device manufacturers.”

Reference: Pear, Robert (2004). “In a Shift, Bush Moves to Block Medical Suits.” New York Times, July 25.

First Lady on Stem Cell Research

On the third anniversary of President Bush’s decision to limit federal funding of embryonic stem cell research to the 78 stem cell lines then in existence, First lady Laura Bush accused opponents of overstating the potential for medical breakthroughs. While rightly pointing out that it is wrong to claim (as some do, or at least insinuate) that the president has banned stem cell research, she was (it seems to us) on shakier ground in asserting that “We don’t even know that stem cell research will provide cures for anything—much less that it’s very close.” We don’t know that it won’t either, we do know that the scientific evidence points strongly in the direction that it could indeed provide cures for many diseases, or at a very minimum contribute substantially to the search for cures.

She said later it’s not fair to raise false hopes “because stem cell research is very, very preliminary,” but again it seems to us unscientific to dismiss hopes (which are essentially hypotheses) as false without first testing them through the scientific method. And if the research is, as she says, “very, very preliminary,” it would seem all the more reason to encourage more of it, not less.

Reference: Unknown (2004). “First Lady Bashes Kerry Stem Cell Stance.” Associated Press via New York Times, August 10.

Republicans Against Stem Cell Research

California Republicans have voted to oppose a November ballot measure that would provide US$3 billion in state bonds for human embryonic stem cell research in California. They “framed their voice vote,” said an Associated Press report, “largely as a budget issue” rather than as an ethics issue.

Reference: Unknown (2004). “Calif. GOP Opposes Stem Cell Proposition.” Associated Press via New York Times, August 8.

Stem Cell Research: UK vs. US

The government-backed UK Stem Cell Bank will become operational within a few months, putting the UK in a leading position to conduct stem cell research—and reap the rewards. In August, notes Elisabeth Rosenthal in an in-depth article for the International Herald Tribune, Britain granted its first license for therapeutic cloning to a group at the University of Newcastle, allowing scientists to create human embryos to harvest stem cells that may be beneficial for treating diseases. All embryonic stem cell lines in the UK will be stored and distributed free through the bank, but their use will be monitored by an ethics panel.

One US researcher told Rosenthal that while British researchers plugged ahead steadily with their work, her group had lost at least two years—”a lifetime”—of research time. She also lost her lab’s former co-director, who moved to Cambridge University so he could continue his work.

The irony is that “the Bush funding ban has not stopped embryonic stem cell research,” writes Rosenthal, “but only slowed its progress and moved the ethically sensitive research into the private sector, where it is entirely unregulated and far more difficult to track.” A British researcher commented that “in the U.S., so long as you have private money, you can do everything—buy embryos, create embryos, do it in your basement. Stuff that we can’t do here.” In Britain, the ethic of societal good trumps what Rosenthal calls the “ethical discomfort” of embryo research, and with its history of having nurtured the world’s first “test tube” baby more than 30 years ago a long debate about the use of human embryos in medicine has resulted in carefully crafted and publicly accepted regulations governing such use. “There is no such legal framework in the United States, where the government relies on “guidelines” and university ethics committees to direct researchers through the ethical maze,” she writes.

Even with a law allowing the creation of embryonic stem cell lines and therapeutic cloning, the process is “deliberate and slow,” with review of every project, tracking of each embryo, and compulsory deposit of every new stem cell line in the national bank, “where it is evaluated and maintained, and may not be transferred elsewhere without approval from a government steering committee.” Reproductive cloning is banned and punished with jail.

Reference: Rosenthal, Elisabeth (2004). “British stem cell studies push past U.S.“ International Herald Tribune, August 23.

Cashing in on US Conservatism

Alan Colman, a leader of the team of geneticists that cloned Dolly the sheep, moved from Scotland to Singapore to create insulin-producing stem cells to cure diabetics. He moved because Singapore “dangled a $6 million grant if he’d agree to relocate,” writes Stuart Luman in Wired. He is not alone—the tiny city-state is spending US$2 billion recruiting scientists in many biomedical fields with offers of grants and top-class labs, and today “a third of the almost 4,000 science PhDs here are foreigners, many with impressive r”sumes.”

To give some idea of just how formidable Singapore has become as a biomed research center, Luman names the following superstars who, like Colman, have made the move:

• Edison Liu, former director of the US National Cancer Institute’s Division of Clinical Sciences, (moved in 2001 to head the Genome Institute of Singapore);
• Yoshiaki Ito, a cancer researcher who brought his entire Kyoto University team to Singapore”s Institute of Molecular and Cell Biology in 2002;
• Nobel laureate Sydney Brenner, a molecular biologist who “splits his time between the Salk Institute for Biological Studies in San Diego and advising Singapore on how to attract more people like him.”
• Martin Hibberd, who left London’s Imperial College to run the population genetics lab at the Genome Institute.Singapore has also attracted multinational pharmaceutical companies, including Novartis, and is nearing completion by year”s end of a $300 million, 2 million-square-foot complex called “Biopolis,” whose institutes will specialize in “bioinformatics, genomics, molecular biology, and nanotech – not to mention a shopping mall, a fitness center, restaurants, a day care center, lecture halls, a pub, and a light-rail system.” The foreign scientists are expected to train an emerging generation of Singaporean researchers, which is a bit of a challenge given the Singapore education system’s focus on rote-learning and a cultural bias for conformity rather than creativity.

Reference: Luman, Stuart (2004). “Singapore Wants You!“ Wired, issue 12.08, August.

Globalization of Drug Development

Drug makers in the United States and Europe are increasingly moving clinical trials and research work to India, reports N. Srinivasan of the Associated Press. Indian firms earned US$54 million in revenue from such work last year, paltry compared to the $12.5 billion it earns annually from information technology outsourcing, but with GlaxoSmithKline, Bayer, Aventis, and Pfizer already outsourcing R&D to India, annual revenues are projected to grow to $5 billion in five years.

Reference: Srinivasan, N. (2004). “Drug Firms in United States, Europe Move Biotech Work to India.” Associated Press via Technology Review, August 11.