CareTalk Podcast Episode 136 - TED Speaker, Juan Enriquez, On Technology, Genome & Healthcare

this podcast is supported by ihi also known as the institute for healthcare improvement who have been improving health and healthcare worldwide for 30 years improvement science is multi-disciplinary and combines expert subject knowledge with improvement methods and tools it emphasizes innovation rapid cycle testing in the field and spread in order to generate learnings about what changes and in which contexts to produce improvements ihi's free quality improvement essentials toolkit is the must-have tool for any quality improvement project download the toolkit by visiting ihi.org while you're there check out the many other tools and free resources available from ihi including qi tools health equity reports and patient safety tools to name a few that's ihi.org check it out today welcome to caretalk your weekly home for incisive debate about healthcare business and policy i'm david williams president of health business group and i'm john drosco the ceo of carecentrics david who do we have as our victim this week well john you're our victim this week but we have a star player this week named juan enriquez he is an academic a businessman and a speaker and we certainly need a speaker uh here john since you and i are both a little tickled with the tongue so uh he's a leading authority on many things and in particular the economic and political impact of the life sciences which is something that we are not expert on even though we talk about it welcome one welcome one so what how did you get interested in kind of biotech and life sciences so i had a uh a very strange career i grew up in mexico i thought i'd always live in mexico i was interested in politics and government um and then had all kinds of adventures ended up exiled out of mexico for trying to reform democracy and uh started trying to figure out why countries appear and disappear and the answer had to do with the ability to adapt to new technologies and at that point the new technology that was sort of bright and shiny was something called genomics but it was the early 90s so i could read the whole field and what and since that period i mean you could argue that the [Music] life sciences have kind of saved the world with the vaccines um you could also argue that they almost priced themselves out of the out of reach for most of the world what's your observation now of its of its promise and its performance so you know i think the topic of health care is absolutely fundamental to the future of the us economy because you know it's close to it's approaching one-fifth of the entire economy it's not getting faster better cheaper and the outcomes in terms of quality of life and disability life years is nowhere near as good as the other oecd countries so basically what you're doing is you're putting a five to ten percent tax extra per output on almost anything produced in the us so when we talk about you know technology getting faster better cheaper there's some things that seem to be getting better perhaps on on healthcare technology but faster and cheaper it does not seem to be the case at least in the us is there any particular reason for that well better you know per dollar spent and per life span the us is not at the top of the charts in terms of ocd lifespans and it's not at the top in terms of healthy life so i i would say better if you have an obscure disease if you've got an orphan disease if you need a very highly specialized treatment yeah you can get some of the best care on the planet um in the us but in general per dollar spent it ain't fast or better or cheaper um there is a turning point which is a really interesting turning point which we may or may not be approaching where the art of medicine starts turning into the science of medicine and in the measure that you can have medicine that looks more like theoretical physics where you predict what's going to be the outcome of the experiment then there is a possibility of getting on a faster better cheaper course in the measure that you start having electroceutical treatments instead of chemical treatments then there is a possibility that you do faster better cheaper in the measure that you decentralize treatments are able to print your own medicines are able to repurpose consumer grade brain machine interfaces towards treatment then possibly you get faster better cheaper but we're just not there yet but i don't know whether politically one the cartels that represent the rent seekers in healthcare are ever going to give up their strong positions i mean i i where i was going with the you know farm farm farm a big pharma small pharma life sciences pharma there's all kinds of examples of bad behavior anti-competitive behavior excess pricing and more of an investment in protecting protectionist policies than actual r d at a time when there's never been more exciting opportunities to literally do things like cure cancer we've got really there's a tremendous amount of scientific and and medical creativity in tailwind but no real uh pricing pressure to alleviate uh you know the excess tax that uh high prices particularly in the us are are sort of creating for that that eventually insinuate themselves into every every as your point everything that's produced in america every hour of labor that whether where there's any health insurance um how do you how do you square that because where we have we are at the cusp of uh of an extraordin almost an accelerating series of uh of of innovations but the the with with absolutely no price pressure so i think you're absolutely right and one of the most fascinating recent examples is the cove indexing so between the time that they had the sequence and the time that they designed the vaccine against cobit it took maybe a couple of hours like literally a few hours and then all of the rest was scaling up the manufacturing and going through immense regulatory hurdles without a challenge trial during a time when close to american a million americans were going to die and you know one of the tragedies of medicine today is that we don't measure the cost of not acting so we certainly measure you know this medicine hurt 20 people and benefited 10 000.

but we never measure the cost of having statins in the united states much later than europe and if you believe that statins save lives then the period of time between the time that the statins were approved in europe and here is the period of time where you killed people for not acting faster and and this applies to university irbs this applies to regulatory agencies this applies to the pharma and part of the problem is the the incentives are so ass backwards so let's imagine for a second that you have two people sitting outside a big pharma ceo office and one person has a life-saving antibiotic it's cheap you take it for seven days and you're cured and you don't come back and the other person has a cancer medication that costs you know a million bucks a year that you have to continuously take that is only going to expand your life for a few months or a few years so the current economic incentive system is to go for the second even though the first one in societal terms is far more valuable to the people in society far more effective for government spending and far more effective a medicine and when you when you look at what we could do with preventative medicine what we could do with antibiotics what we could do with basic nutrition what we could do with um just antiseptics and just general preventive care you really could increase lifespan and quality of life in a very substantial way if that was your focus but instead we tend to focus on more and more expensive drugs for fewer and fewer people create vouchers for obscure drugs for small groups of people and if you're part of that small group you're very happy you live here if you've got insurance but as a whole society we're all paying a whole lot more than other people are paying for a whole lot less of an outcome but i mean certainly the operation warp speed uh focused on something that was hitting everybody and the government paid for it and got pretty quickly uh to people in the u.s compared with elsewhere has that changed the equation or made people realize hey maybe maybe we actually want to focus on these broadly based uh issues as opposed to the you know the orphan drugs i hope so um you know we almost put all the vaccine companies out of business they came very close to going out of business and there's very few things that are more effective than a vaccine per dollar spent it's crazy to me that we had fda approved vaccines against lyme disease and the anti-vaxxers and the liability were so high that those vaccines were pulled so you're now in a situation where you can go to martha's veneer connecticut or maine and vaccinate your dog against lyme disease but you can't vaccinate your kid and you've got more and more people with a nasty chronic disease that's going to affect them for a long time because we're not good at the preventive part because we're very good at looking at the risks we're very good at making a lot of lawyers rich off those risks and we're not very good at protecting our own citizens juan you you gave a really provocative talk one time which sort of suggested that the fda approval process just to pick one thing that could be improved had basically created the reverse of moore's law in innovation in drugs and devices do you still hold to that that we're kind of reversing the the speed of innovation in medical technology through regulation you know when i gave that talk it cost a hundred two hundred million dollars to bring a drug to market and it's now approaching a billion so yeah moore's law is operating in reverse in this and you know there was a i used as an illustration a an anecdote in dc which was there used to be a time when people could still drive along the beltway and actually move now it's a parking lot and during that time every morning in the same place the damn beltway backed up and the traffic engineers just could not figure out why in the world is this thing backing up and so they looked at this and they looked at that and then finally somebody wrote into the washington post and said there's this one guy who gets on the beltway he goes to the far left-hand side he goes 50 miles an hour and doesn't move and people honk at him people scream at him he just backs everything up well lo and behold a few days later in comes a letter to the washington post saying my name is john nestor i'm the person who does it i'm following the letter of the law the speed limit is 50. if somebody else wants a speed that's their problem i'm going to follow a letter of law that led the good citizens of washington dc to invent a verb called nester in honor of this gentleman now guess where john nestor worked he actually worked at the fda and what the law says is you have to have a drug that's safe before you approve it and guess what no drug is safe all drugs have long lists of interactions so nestor never approved a drug and this got so ridiculous that finally he was fired ralph nader sued for his reinstatement arguing he's just following the letter of the law he did his entire career at the fda and never approved a single drug but blocked everything that came to his desk and ironically at one point he was in charge of the renal division and he died of kidney failure so he could have actually approved a drug that may have saved them that's right i'm not sure where john's going to go with that and i remember the i think the the maryland police copied that one instead of taking up one lane they'd actually went across the whole the whole beltway and uh and made sure people were going at that at that slow pace i think the lyme disease is really an instructive one and maybe tells us where we are in terms of a turning point because i was hopeful that maybe once the cova vaccine came out that people would be okay excited about vaccines and then those that were sort of against uh you know some of the childhood vaccines because they didn't remember what it was like to have terrible childhood diseases would we engage with them it seems like we may be going the other direction with that way whereas i i had lyme disease i had actually had the classic symptoms and caught it right away and didn't have problems but that could easily have not have happened and i could get it again so i've actually been hoping for lyme disease vaccine as well do you think are you optimistic pessimistic i mean where could where could it go and can we influence it so i think what's fascinating about today's medical system is the prices and the output are so completely out of whack that if i were advising the canadian government or if i were advising the mexican government or if i'm advising the taiwanese government or you know name a place that has a decent pharma structure i would look at the case study of taxi cabs and ubers i mean coming back to washington dc washington dc had a notoriously bad taxi service called barwood and you just never knew if you could possibly get a cab and if they didn't show up they said well sorry we didn't show up and getting a medallion in new york city was so expensive that nobody could afford them and so you you end up with these systems where the regulation and the practice drives the delivery to the customer so far out of whack that another country can come in and say you know what come across the board and we'll give you a lyme disease vaccine or come across the border and we will give you a better covet vaccine for the new variant or come across and do x y or z and in the measure that those are reasonably priced options then a lot of people are going to be willing to pay out of pocket um you see it with things like plastic surgery right you see it with some fertility treatments where people really spend a lot of money for specific procedures or specific treatments as long as they think they are effective and there is such a gap between the cost of a really great lasik surgery in india and the united states or the cost of a hip replacement in india and the united states with the u.s

trained doctors that a lot of people are taking you know a business class trip over there enjoying india and i think you're going to see more and more of that medical tourism and you will soon see pharmaceutical turf because if you don't develop the vaccines here you know if i were there's a spectacular book by david halberstam called the reckoning as to how the asians took out the largest most powerful industry in the world which was the us auto industry and it was basically they were building really bad things in detroit with planned obsolescence and to my mind a lot of the pharma industry and the medical industry feels like that i don't know whether you saw one but there is actually a new pbm that uh pharmacy benefits manager that is for mid-tier employers and one of its angles is it's buying drugs from canada and just reselling them here because it turns out in certain states that's quite legal and uh there you're you're starting to even see it you sort of emerge in in fifths and spurts just because the dislocation of the the price disparity is is is humongous i mean they're they're and it's for the same chemical compound the same biologic and i think that i think you're absolutely right i guess are there are there other ways that we could structurally improve the incentives to to sort of tie more outcomes or price sanity to a system where pricing has really gotten just completely detached from either the cost to production or research or or outcome so i i've always been a fan of zero-based budgeting and you know you can say hey um we as a society are willing to spend 15 in gdp for health care or we're willing to spend 19 whatever the number is and and then adopt something that the brits have actually gotten very good at which is daily disability life years so if i treat a child for an earache with an antibiotic that has huge disability life years if i treat a child for basic vaccines when they're born just diphtheria tetanus the rest of stuff huge disability life years very low cost huge outcome if i treat you know a smoker with a second kidney transplant or a second lung transplant the disability life years are minimal at a huge cost and you know one of the ways that i think about how we budget health care in the united states is i think if we treated education the same way you would basically tell kids we are not going to pay for your grammar school we're not going to pay for your high school we're not going to pay for your college we're not going to pay for your graduate school however if you reach age 65 you can take any course at any school at any price regardless of outcome and it's just such an insane system right because what what you need to do is you need to fund the stuff that provides the longest high quality of life first and if you've got money left over then you know maybe you do the second lung transplant if you're willing to tax a society to that level what you shouldn't be doing is you shouldn't be putting huge debts on future generations because you want to maintain a crazy system that makes you an atm for a hospital at the very end of life right most of your medical spending is doctor do everything possible and oh by the way most doctors have directives that specifically mandate against doing a lot of the things that we are doing to our elderly we wouldn't treat our dogs in the way that we treat someone or elderly right you it's okay if you live in pain for extraordinary periods of time it's okay if you live in you know horrendous intubated brain dead position for a long period of time you you wouldn't dream of treating here how does how does the uk get it get get apply that concept in real life is it because the nhs gets to make centralized decisions and we've distributed decision making and as a result we don't have any yes and i want to be very specific there are huge problems with the nhs in terms of delivery of services and and i think when you look at these systems you've got to look partly at what canada does partly what sweden does partly what the uk does and mix and match to create a best-in-class system but what the uk does specifically when it approves a new medicine and looks at the price of new medicine is it says how many good years of quality of life will this medicine this operation this implant this medical device provide and and that's what the decision is based on so juan it's been i always love watching your talks when you talk about the technology and saying like where does it where does it go from here in the long run uh impacts there was one that i went back to from a little while ago where you talked about the age of genetic wonder and there was something that i picked up on that i thought would be useful for now i just wanted to get an update on it where you were talking about being on track for close to carbon neutral fuels by 2025 which i think could impact probably some of the things that are going on in in europe at the moment if that were coming to bear how are we doing on the on the fuel side of things so you know it's a race between fuels and it's a great race because there are places where it's going to be very hard substitute liquid fuels for the rest of it the price of solar wind and geothermal is dropping so fast that pretty soon it's not going to make sense to burn coal in fact it doesn't in most places today on subsidized coal it doesn't make sense in a bunch of places like the alberta tar sands to generate fuel there will be a point where you will get to a price point where it is cheaper to use solar or geothermal wind than even saudi crude and that's not that far off and and then you still have places where the energy density of liquids is such that it makes it impossible to fly plane with batteries or it may make more sense on heavy transport ship to use fuels and there you do have to have carbon neutral fuels and the way you do that is you have cells that you program to basically generate fuel and and that sounds like science fiction until you understand what gasoline or oil is so so in essence if you think of a palm tree a palm tree is a whole series of solar panels that are hit by photons from the sun and that same energy from the sun that warms or burns your skin powers the palm tree it allows it to grow it allows it to you know bring up juices grow bark grow wood when you rot that under pressure for a million years you get a rotten soup of vegetables and plants and trees and bogs and that's called oil and you refine that and that becomes gasoline so it's sunlight stored in organic matter that generates oil and gasoline and what we're trying to do with these fuels is to go short circuit that cycle and go direct sunlight to cell and make that cell a factory for the fuel without the intermediate 1 million years of cooking under pressure we're getting to the point where we could see a commercial facility beginning to be deployed by 20 25 26 on a pilot basis we are already flying some planes using you know discarded cooking oil but that's very hard to scale um and we should see we should see some of these fuels coming online especially with today's price of oil and some of today's subsidies well and also the geopolitical implications of being dependent on it i mean have never been so stark as to as i think this war is pointing out which is really the the the you know the geopolitical thugs have often you have been fueled by oil i mean they're there there's uh but i'm surprised you didn't bring up the the the the emerging technologies in nuclear that that appear to be a lot safer um a a lot more productive and and relatively quick you know those technologies are available today and with a possibility of hydrogen i mean it just feels like uh solar uh when geothermal those are still partial solutions but if you were to add a couple of other components you might have you know a full stack yeah i agree with that and especially if you're gonna start traveling long distances in space or you're going to have to power moon bases or other things nuclear has to be a component of that the other thing that's happening is you're beginning to develop these pocket nukes yes that you can bury and they're much smaller scale and are not subject to the same kind of blow up and chernobylization of something in the measures that those work again they're competing against a very fast dropping cost of solar and the thing you haven't seen in nuclear is you haven't seen the same kind of faster better cheaper curve you could see it right there's no reason why those pocket mutes couldn't go faster better cheaper but again it gets into a very nasty regulatory route that has ratcheted several levels that you have to de-ratchet while maintaining safety hey john do i have time for one more question you do so another thing that you that you uh talk about in the same talk about the age of genetic wonder is about the age of the genome merging into the age of the brain how how how will that be working out so i tend to be a little restless like switch careers every decade or two i think you switch careers actually more frequently than that just not as long as he doesn't do it do it during our show john we're okay okay there we go so you know i got to the point in genomics where once i saw what they were doing with stem cells and once i saw what they were doing was being able to make full genomes and with the reproduction of tissues i became pretty convinced that it's only a matter of time before we're able to reproduce our eyes our teeth our stomachs our lungs so in essence we're going to know how to program cells to make another knee because we've already done it twice or another kidney because we've already done it twice so the program is there and it's a question of how do you execute that program and and we're already doing it with bladders we're already doing it with tracheas we're already doing it with skin right and we'll get to the complex organs and the reason why the brain then becomes the critical component is until you can regrow a brain and download the information into the brain longevity has a limit of 120 130 years all these people who are giving you snake oil about how we're going to live forever etc it doesn't work until you have a downloadable brain and that's a big bloody challenge right so if you want human beings to actually live to 300 500 years you you have to understand the brain and that's something that's going to take us a century or two to be able to do so all these folks were telling you you know 160-year lifespan not not until you solve the brain issue and that's that's why it's so interesting well good i guess the thing is when we live even 160 years never mind 500 we'll have plenty of time to listen to cure talk episodes but i think for now we're going to say thank you juan enriquez academic businessman speaker and career changer i'm david williams president of health business group and i'm john driscoll the ceo cares hendrix one thank you so much for joining us and and and and the the age of wonder of uh of of of science and the aid and the painful reality of health care costs uh bringing us back to earth but thanks for joining us today [Music] you

2022-04-24 20:11

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