Jeffrey Bland (PhD) gives a recorded lecture (Town Hall Seattle, 2008) arguing that U.S. medicine has shifted from acute to predominantly chronic disease care, consuming the majority of healthcare spending and stressing the system. He highlights chronic conditions—type 2 diabetes, cardiovascular disease, autoimmune disorders, digestive disorders—and uses Alzheimer’s as a detailed example of rising cost and social burden. Bland criticizes medical training and reimbursement for favoring high-tech terminal interventions over early prevention, and points to emerging biology (epigenetics, genomics, molecular medicine) as offering opportunities to detect and modify disease trajectories earlier.
Questions this video answers
78%
Almost 40% over the next 25 years
Town Hall Seattle; recorded June 17, 2008
Chapters
Full circle now, when we hear about health reform, starting with Hillary Clinton in the previous Bill Clinton era, going all through those last now nearly 16 years to today, what has the debate been around? It's been access to care and reimbursement. Who's going to pay for surgery, who's going to pay for drugs, who can get to the hospital first? Do we have health insurance for all people or are we discriminatory? Now, these are all beneficial reasons for debate. I'm not suggesting we should throw the baby out with the bathwater. However, I hear very little discussion about what drives people to hospitalization and to surgery and to pharmacotherapy. It would be interesting, would it not, entertain the question where did disease come come from? We have moved as our culture in the last 50 years from a culture where disease patterns were principally acute diseases, to where the principal disease patterns today are chronic disease. 78% of healthcare expenditures today go to chronic disease management. Number one on the list is type 2 diabetes with all the attended secondary side effects, renal failure, ocular injury, neurological problems, you know, all the things that happen as a consequence of diabetes, cardiovascular disease as well. But beyond that we've got increasing incidence of certain families of autoimmune disease, particularly systemic. Lupus Erythematosis is on the rise. Thyroiditis is on the rise. I could go down the list. Chronic digestive disorders, esophageal reflux disorder. You can't really even be a fully functional 40 year old unless you can talk about your esophageal reflux disorder, right? So I mean we have so many functional problems that are precedence to the later stage acute disease where we only spend 22% of our health care dollars but our medical doctors in training spend 95% of their time learning how to manage those acute diseases. So as Halstead Holman, dean of the University of Stanford University Medical School says it in a wonderful editorial in the Journal of the American Medical association in 2005, he asked the question, are we in need of a new clinical education? A new clinical education focuses not just on acute care medicine involved with hospitalization, but the chronic disease ambulatory care model. The model that you know, is a difficult model to apply because people generally don't get immediately well, they don't have self limiting acute disease, they die every well, they stay in a chronic state of infirmity with functional disabilities. Now let's take one such example, Alzheimer's disease. A very interesting example, is it not? Alzheimer's disease is a kind of a nice, what we call medical taxonomy. It's a term, it's like Linnaean biology. We always feel better if we can call something something. I mean, it's like, okay, now you say that that person has Alzheimer's, what do you do for them? Well, we have these wonderful drugs like Tacrine or Aricep. These are horrible drugs. They're horrible drugs. You look at the scientific papers that have been published in the most premier journals, the Journal of Neurology, the New England Journal of Medicine, these drugs don't work. You know that if you've ever seen Alzheimer's patients, that these drugs are poor drugs. So where did Alzheimer's disease come from and where is it going? It said right now at the rate of increase of Alzheimer's dimension in our population, that over the course of the next 25 years it will take almost 40% of the healthcare dollars just to manage Alzheimer's patients. So we become an aging America of infirm people putting a burden on a society of younger people who are limited in number through this picket of python called the Baby Boomers. So all these aging Post World War II baby boomers are going to be supported in Alzheimer's clinics by a few number of young working people, all who are chronically ill. Because now what we find, because what we find. I'm now quoting from Kostakoff's book, by the way, called the Coming Demographic Storm. And in that book what he points out is that if you look at the younger people of this country, I'm not talking about teenagers and young 20 year olds, that their health patterns are in fact, the New England Journal of Medicine published a paper again in 2005. Some of you know this, which was a wake up call to all medicine saying, based upon what is going on right now with our youth, the suggestion is that this will be the first generation born in the history of the United States was expected to live shorter than their parents. That's when we're spending twice per capita on healthcare. Now these are all wake up calls. I'm not making these figures up. This is not my interpretation because these are in the highest quality peer reviewed medical literature. Whether you're a healthcare planet, a policymaker, a medical educator, a patient, a provider, this is a sea change as Dr. Brazaro was talking about, that we're confronting. So now that's the alarming news. The good news I want to give you the cup half full now rather than the cup half empty is that on the other side we are for the first time starting to uncover the origin of chronic age related Disease. There is a new biology that's emerging rooted in epigenetics, rooted in the human genome project, rooted in molecular medicine, rooted in functionality, so that we don't wait until a person is so broken that what they need is an organ transplant or to be put in a terminal care facility. We look early on when the trajectory of that dysfunction is such a level that we can modify earlier research rather than later, because once you get to later, you know the problem. It's heroics. And we keep people held together with Bailey bar and bubblegum the best we can. Now I'm involved with some research, involved with biotechnology and some cancer research. I go to these big biotech conferences and it's been alarming to me. Maybe I've got a problem. Solve the sheriff and I'll offload my problem to you. The problem is I go to these very, very remarkable high tech discussions with the scientists from the world's class institutions who are talking about this major breakthrough they've had in managing a specific form of cancer with a new drug, something like a kinase inhibitor, in which they're talking about the fact that on average, this drug, which will cost three to four thousand dollars a week, will extend mean life expectancies by two weeks. Now, what is this all about, by the way? I'm not making this up. This is true. And these drugs are being approved. Now, maybe some person will have the luck of the draw because they're the outlier or they'll have complete remission. But on average, the benefit that you can tell that patient is we're going to give you two more weeks of life. By the way, it's also going to have serious side effects during your two weeks. So. So the point I'm trying to say here is that we're caught up in a very interesting conundrum. We have these tools for the first time that can allow us to understand the origin of disease way earlier than we've ever been able to understand starting the root origin of dysfunction well before you get pathology. But what we do in our medical system is reward people for doing the most at the terminal end of life. In fact, in our culture, if you aspire in medicine to be financially successful, you want to be trained to do the weirdest things, right? The more you can intervene with bizarreness, the more you will be valued. Doing simple things like telling a person how to exercise, eat right, live right, manage stress, change your environment. That's like low tech, that has no value. That's like public service stuff. The real stuff is doing things that no sci fi movie 30 years ago would even think was reasonable. That's where you really get the great reimbursement, because you must be pretty good to be able to do that stuff. So what I'm suggesting to you is that the whole value system we have to aspire for young minds who are brilliant to be realized as great and is reinforcing more doingness of bizarreness and less enlisting that genius, that creative understanding to keep people from needing bizarreness. Now if you don't understand what I'm saying, let me give you an example. I'm going to show a quick little video vignette. We are fortunate. We see a lot of patients out in our Gig harbor facility and we see patients.
