The theme of this year's Lindau Meeting of Nobel Laureates is the future of medicine, and it played host to a panel discussion on the prospects for biomedicine that featured Peter Agre, Aaron Ciechanover, Martin Evans, and Ferid Murad. The panel discussed the promise of stem cells and personalized medicine, but felt that it would be decades before much of this promise will really come to the fore. But that doesn't mean that big gains in health aren't possible in the short-term—it's just that they don't involve progress in the field of medicine.
Aaron Ciechanover, who won the Nobel in chemistry, was very excited about the prospects of personalized medicine, which will require appropriate genetic profiles, including a genome sequence and an understanding of epigenetic modifications. Both of these are available to researchers and a few individuals now, but this sort of information won't be mainstream for a while yet. Ciechanover suggested we'd also need to profile things like the expression of small RNAs and chemical modifications of proteins; neither of these are anywhere close to being able to be performed for large populations.
If we ever get there, however, Ciechanover's expectation is that it will place a heavier emphasis on preventative medicine, as people will have some sense of what diseases they're susceptible to, and can adjust diet and activity accordingly. It will also allow therapies to be targeted specifically to diseases; instead of giving someone a therapy and waiting to see if they respond, we should be able to pick the appropriate one based on genetic information. Of course, that may require additional genetic profiling of the disease state.
Ciechanover also pointed out that it had non-medical implications: maintaining privacy of the information, and the potential for conflicts between commercial interests in genetic information and the individuals that should, in theory, "own" their own genomes. He also said that cost could be a barrier to its widespread application, a point that was echoed by a Pakistani doctor in the audience—we may end up needing to decide whether only the wealthiest nations or individuals will have access to the full suite of our medical technology.
The issue of cost is already plaguing wealthy nations, though, as Ferid Murad reminded the audience. (Murad got the Prize for elaborating the signaling role of nitric oxide, which regulates blood flow; this has implications for heart disease and has been targeted by drugs like Viagra). Murad blamed a couple of issues that may be US-specific: a tendency to sue over everything and an over-reliance on emergency medicine for basic health services. The fear of lawsuits isn't just felt in terms of malpractice insurance; Murad suggested that doctors perform lots of unnecessary tests to limit their risk of lawsuit. Personalized medicine, Murad thought, might help control some of this by letting us more rationally target treatments, but it won't be able to overcome these more general issues.
Nearly the entire panel had some thoughts about how we tend to spend huge quantities of money on end-of-life care, often after a patient has no chance of recovery, although nobody had a good idea about how to constrain these costs. They were also concerns raised about the high price of some recent drugs, like those based on antibodies that bind to the proteins that drive certain diseases.
Martin Evans suggested stem cell therapies also showed enormous promise. We spoke to him about the prospects for these therapies, and we'll have his detailed thoughts in another story.
Hope for the near term
Both future prospects—stem cells and personalized medicine—also may end up exacerbating the problem of medical costs. And, even though everyone was optimistic, panelist Peter Agre cautioned that the sort of progress the panel expected doesn't always come to pass in the way we expect. Depressing enough?
Fortunately, the panel did offer hope for some shorter-term improvements. The surprise was that none of them involved medical advances; most involved policy or education.
Murad suggested the solutions for the problems he identified involved policy changes, including a cap on the amount of money that can be paid in malpractice suits; Ciechanover suggested the same might apply to drugs, as he considered Vioxx a "fantastic" drug that was taken off the market primarily due to the threat of lawsuits, even though relatively few people were at risk of fatal complications. Murad also called for greater education, some of it devoted to physicians, who he suggested could use a refresher on what tests are actually medically necessary.
Peter Agre (an MD himself) quickly pointed out that patients are a problem too. He and Murad concluded that patients need to have a better understanding of how to use the care that's available to them cost effectively, and to use the drugs that are prescribed to them well. Taking drugs improperly can not only harm the patients themselves but, in the case of antibiotics, has helped produce drug resistance that place all of society at risk.
The education shouldn't stop at drugs, however. Agre also noted that many of the biggest public health problems are a result of lifestyle choices. Cigarette smoking is a major cause of preventable illnesses, but it's far from the only one—Agre mentioned melanoma and colon cancer as being similar in nature. Public awareness and education, in the form of the surgeon general's statement on the risks of cigarette smoking and cancer and the recently updated FDA warnings on packaging can have a significant impact here, he argued. But their impact is much greater if they're packaged with actual enforcement efforts; Agre praised New York City Mayor Mike Bloomberg's efforts, which included education, resources for quitting, indoor smoking bans, and an increase in the tax on cigarette packages.
The panel in general felt that good governance and the infrastructure it enables are an essential part of healthcare. Murad contrasted the occurrence of post-earthquake experience in Haiti and Japan (only one has suffered severe epidemics) to note just how significant the role of effective governance could be in the case of natural disasters, but suggested that the role extended beyond crises, as things like basic sanitation and clean water can help improve health under all circumstances. And Agre suggested there might be places for more efforts like the one spearheaded by Bloomberg; as more nations are increasing their standards of living, the health problems that the industrialized world is now facing, like obesity and smoking, are striking them, as well.
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