Health Care’s ‘Upstream’ Conundrum

When it comes to the long-term health of the country, findings now show the big problem might not be health care at all—it might be everything else. Can researchers get politicians to pay attention?

From my article in January 2018 in Politico

At the heart of America’s vaunted health care system is a frustrating puzzle. The United States pays three times as much per citizen as the average of other wealthy nations—far more than even the second-highest spender, Switzerland, adding up to $3 trillion a year. Yet for all that enormous expenditure, we come in dead last among those nations in lifespan. And as the bills climb, our life expectancy is actually shrinking.

What’s going so wrong? If our national health care were a corporation, that return on investment would get its CEO immediately fired. Plenty of experts are ready to point fingers at various causes: our lack of universal health care, industrialized food system, PoliticoUpstreamsuburban lifestyles, and profit-driven tangle of insurers and drug companies and hospitals. Surely those play a role. And yet other countries face each of these, and other challenges as well, and still manage to spend less and enjoy better health overall.

Looming over the American conversation about public health is a growing suspicion that there’s a bigger reason for our uniquely poor showing, one that has been staring us in the face for years. It’s an explanation rooted in one simple statistic: While we pay more for health care than any other country in the world, when it comes to spending on social services—education, subsidized housing, food assistance and more—we rank in the bottom 10 among developed countries.

It’s easy to think of “health” as just another category of social-service spending. But a great deal of modern research suggests that it might be more accurate to think of it as the payoff of all the other services put together. Elizabeth Bradley, president of Vassar College and a former Yale researcher widely seen as the world’s foremost expert in the relationship between social services and health, has documented how the ratio of a country’s social-service spending to health care spending is highly correlated with health outcomes around the world. “The right question for our political agenda is, ‘What’s going to give us the most bang for the buck in health outcomes?'” says Bradley. “What our work has shown is that the answer is spending on social services.” Read more

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The missing Alzheimer’s pill

America faces explosive growth in chronic disease, but our drug system is set up to fail in fighting it. What needs to happen?

From my article in December 2017 in Politico

PoliticoAlz

If there’s a dream of what a new drug is supposed to do, it might look something like Kalydeco. In 2012, the new light-blue pill from Vertex Pharmaceuticals rocked the world of cystic fibrosis, a fatal disease that affects 30,000 people in the United State. It’s best known for its attack on the lungs, slowly suffocating its victims while attacking other organs—but when patients got the drug in its experimental phase, some started reporting such enormous improvement in their breathing and energy they were able to take up running, even marathoning.

Kalydeco is emblematic of the promise of new approaches in drug development. Built on a new understanding of how a particular defect in a gene can disrupt the workings of the body, the drug zeroes in on critical proteins inside cells to keep them functioning. “The drug was so good it broke the blind,” says Bernard Munos, a senior fellow at FasterCures, a think tank based at the Milken Institute—meaning the positive trial results were so clear that patients and doctors could easily tell who was receiving the drug and who got a placebo.

At the same time, Kalydeco serves as a cautionary tale. “The results for the patients it helps are absolutely spectacular, but those patients are only a sliver of the population with the disease,” says Munos. If you haven’t heard of Kalydeco—and you probably haven’t—that’s because this drug, which costs the U.S. health care system nearly half a billion dollars per year, currently helps fewer than 2,000 American patients.

The drug-development system that produced Kalydeco is one of proudest achievements of American medicine, and one of our biggest investments as a society. When American leaders talk about “innovation” in health care, they’re largely talking about the development of new pharmaceuticals. But as America looks squarely at the biggest health challenges of the future, there’s reason to worry that the system we’ve built may not be adequate to what’s in front of us. When it comes to the two diseases likely to become our biggest killers— Alzheimer’s and diabetes—death rates are relentlessly ticking up, with few solutions on the horizon. Read more

A Reality Check for IBM’s AI Ambitions

IBM may have overhyped its Watson machine-learning system, but the company still could have the best access to the kind of data needed to make medicine much smarter.

From my article in the July/August 2017 issue of MIT Technology Review

Paul Tang was with his wife in the hospital just after her knee replacement surgery, a procedure performed on about 700,000 people in the U.S. every year. The surgeon came by, and Tang, who is himself a primary-care physician, asked when he expected her to be Watsonback at her normal routines, given his experience with patients like her. The surgeon kept giving vague non-answers. “Finally it hit me,” says Tang. “He didn’t know.” Tang would soon learn that most physicians don’t know how their patients do in the ordinary measures of life back at home and at work—the measures that most matter to patients.

Tang still sees patients as a physician, but he’s also chief health transformation officer for IBM’s Watson Health (see “50 Smartest Companies 2017.”) That’s the business group developing health-care applications for Watson, the machine-learning system that IBM is essentially betting its future on. Watson could deliver information that physicians are not getting now, says Tang. It could tell a doctor, for instance, how long it took for patients similar to Tang’s wife to be walking without pain, or climbing stairs. It could even help analyze images and tissue samples and determine the best treatments for any given patient.

But lately, much of the press for Watson has been bad. A heavily promoted collaboration with the M.D. Anderson Cancer Center in Houston fell apart this year. As IBM’s revenue has swooned and its stock price has seesawed, analysts have been questioning when Watson will actually deliver much value. “Watson is a joke,” Chamath Palihapitiya, an influential tech investor who founded the VC firm Social Capital, said on CNBC in May.

But if Watson has not, as of yet, accomplished a great deal, one big reason is that it needs certain types of data to be “trained.” And in many cases such data is in very short supply or difficult to access. That’s not a problem unique to Watson. It’s a catch-22 facing the entire field of machine learning for health care. Read more

How Your Suburb Can Make You Thinner

Inside the new movement to engineer healthier lives for Americans by rethinking the places they live

From my article in May 2017 in Politico

To appreciate the classic American town, go to Europe. The narrow streets of most European cities and towns meander past a parade of tightly packed homes, cafes, shops, markets and parks, all teeming with people on foot. Today, we think of this buzzing pedestrian existence as the kind of quaint thing you plan a vacation to experience. It used to be daily life for Americans too, says James Sallis, a public-health and behavioral medicine researcher at the University of California, San Diego—right up until the early middle of the 20th century, when we started rebuilding the American community around PoliticoSuburbthe automobile. “People liked riding in cars, and so we got the suburbs,” he says. “Now everybody has privacy, quiet and space.”

What they also got, Sallis adds, was fat and unhealthy. Suburban Americans came to build their lives around sitting—sitting on the sofa, sitting at an office desk and, most of all, sitting in the car. The car became essential, increasingly so as work shifted from the local factory to offices in the city; as the local butcher, baker and grocer were replaced by more distant supermarkets; as malls three towns over pulled business from local shops. Kids went from meeting up with friends at nearby playgrounds or soda shops to being shepherded in a car from school to math tutoring to tae kwon do to soccer practice. Lost along the way were the daily walking and biking that used to get people from place to place in their self-contained communities.

This loss might not be worth mourning as more than the march of progress, if it weren’t for the bonus it had quietly been delivering. We now have decades of ever-growing, nearly incontrovertible evidence that moving our bodies on a regular basis is a very healthy thing to do, and the loss of this habit in America has taken a horrific toll. Eight hours or more a day of sitting nearly doubles the risk of Type 2 diabetes and sharply increases risks for heart disease, cancer and earlier death, according to research from the University of Utah and the University of Colorado. The average American sits more than nine hours a day.

If people can’t be cajoled to walk for its own sake, is there another way to get them moving? In recent years, planners and policymakers have begun to pull back and consider another solution: If suburbs are the problem, maybe suburbs can be re-imagined as the solution. People drive because their neighborhoods encourage it—and sometimes even leave them with no choice. What, then, if their neighborhoods were built to foster walking? With the right layout and development, the notion goes, our suburban towns and sprawling new cities might become havens of human-powered rather than petroleum-fired motion. Along the way, health should soar. Read more

Self-Driving Trucks

Tractor-trailers without a human at the wheel will soon barrel onto highways near you. What will this mean for the nation’s 1.7 million truck drivers?

From my article in the March/April 2017 issue of MIT Technology Review

Roman Mugriyev was driving his long-haul 18-wheeler down a two-lane Texas highway when he saw an oncoming car drift into his lane just a few hundred feet ahead. There was a ditch to his right and more oncoming cars to his left, so there was little for him to Truckdo but hit his horn and brake. “I could hear the man who taught me to drive telling me what he always said was rule number one: ‘Don’t hurt anybody,’” Mugriyev recalls.

But it wasn’t going to work out that way. The errant car collided with the front of Mugriyev’s truck. It shattered his front axle, and he struggled to keep his truck and the wrecked car now fused to it from hitting anyone else as it barreled down the road. After Mugriyev finally came to a stop, he learned that the woman driving the car had been killed in the collision.

Could a computer have done better at the wheel? Or would it have done worse?

We will probably find out in the next few years, because multiple companies are now testing self-driving trucks. Although many technical problems are still unresolved, proponents claim that self-driving trucks will be safer and less costly. “This system often drives better than I do,” says Greg Murphy, who’s been a professional truck driver for 40 years. Read more

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Can a Whole Town Lose Weight Together?

PoliticoMuskegon

A report from a bold experiment in Michigan

From my article in March 2017 in Politico

MUSKEGON, MICH. — Try one of these, says Patti Moran, a drug pusher who operates in a large, humid hut covered by a thick plastic tarp and smelling strongly of dirt. Accepting the dare, I pluck the lurid green item from her hand and put it my mouth. In just a few seconds, I start to feel its effects. I’ve just ingested a leaf pulled off a mustard plant growing at our feet, and I’m thoroughly enjoying the mild wasabi-like burn working its way up my sinuses.

The hut serves as a greenhouse, and it sits in the middle of a 2-acre microfarm right on the grounds of Mercy Health Hospital. It’s not an exaggeration to call this a drug factory: Soon, some of the patients leaving the hospital will come straight here, clutching a prescription from their clinicians for freshly harvested vegetables. Most of the patients will be diabetics or pre-diabetics, but they might also be at high risk for heart disease, or for knee replacement—ills that are exacerbated or even caused by excess weight and poor diets. The vegetable Rx, which doctors will begin adding to some patients’ treatment plans in August, will be a small but important step toward reclaiming their health.

Moran’s prescription greenhouse is just one of a growing matrix of initiatives that are already starting to change attitudes and lifestyles in this rural, Middle American community. Muskegon County has struggled with job loss, large pockets of poverty, and the raft of health challenges that afflict a disproportionate number of American towns far from the coasts. Some of the biggest of these health challenges largely boil down to obesity—a problem that vexes the entire nation and has become particularly acute throughout the Midwest and South, especially in less affluent communities that, like Muskegon, are far from big cities. Read more

The War on Stupid People

American society increasingly mistakes intelligence for human worth

From my article in the July/August 2016 issue of The Atlantic

As recently as the 1950s, possessing only middling intelligence was not likely to severely limit your life’s trajectory. IQ wasn’t a big factor in whom you married, where you lived, or what others thought of you. The qualifications for a good job, whether on an assembly line or behind a desk, mostly revolved around integrity, work ethic, and a knack forAtlStupid getting along—bosses didn’t routinely expect college degrees, much less ask to see SAT scores. As one account of the era put it, hiring decisions were “based on a candidate having a critical skill or two and on soft factors such as eagerness, appearance, family background, and physical characteristics.”

The 2010s, in contrast, are a terrible time to not be brainy. Those who consider themselves bright openly mock others for being less so. Even in this age of rampant concern over microaggressions and victimization, we maintain open season on the nonsmart. People who’d swerve off a cliff rather than use a pejorative for race, religion, physical appearance, or disability are all too happy to drop the s‑bomb: Indeed, degrading others for being “stupid” has become nearly automatic in all forms of disagreement. Read more

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