Improve Performance, Rather than Search for New cures

I’ve just finished reading Better by Atul Gawande. Like his previous book, Complications, this one is full of humane and insightful observations about the complexities of medicine.

There is one particularly fascinating chapter about performance, and how you improve performance in medicine. He tells the story of cystic fibrosis. Medicine has remarkably improved the life expectancy of patients over the last thirty years or so. In the sixties patients made it to just ten years old, now most live into theri mid thirties with some patients living much longer.

Remarkably, Gawande makes the case that this wasn't only to do with better science, it has to do with better medicine. Part of the story is here, in the New Yorker.

We are used to thinking that a doctor’s ability depends mainly on science and skill. The lesson from Minneapolis is that these may be the easiest parts of care. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and consistency and ingenuity can matter enormously.

But in the book version of the same essay he is more confident. And bolder.

"To be sure, we need innovations to expand our knowledge and therapies, whether for CF or childhood lymphoma or heart disease or any of the other countless ways in which the body fails. But we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we've made a science of performance – as we've seen with hand washing, wounded soldiers and child delivery – , however, thousands of lives have been saved. Indeed, scientific effort to improve performance in medicine - an effort that at present gets only a miniscule proportion of scientific budgets - can arguably save more lives in the next decade that the research on the genome, stem cell therapy, cancer vaccines and all the other laboratory work we hear about in the news. The stakes could not be higher."

It is a brilliant vision of a different kind of medicine, one that deals with the here and now, rather than hoping that there is a miracle cure in the future that we should all be waiting for.

The Cost of Drugs

The New York Times ran this story about the increasing cost of a drug.

"The medicine, also known as Mustargen, was developed more than 60 years ago and is among the oldest chemotherapy drugs. For decades, it has been blended into an ointment by pharmacists and used as a topical treatment for a cancer called cutaneous T-cell lymphoma, a form of cancer that mainly affects the skin.

Last August, Merck, which makes Mustargen, sold the rights to manufacture and market it and Cosmegen, another cancer drug, to Ovation Pharmaceuticals, a six-year-old company in Deerfield, Ill., that buys slow-selling medicines from big pharmaceutical companies.

The two drugs are used by fewer than 5,000 patients a year and had combined sales of about $1 million in 2004.

Now Ovation has raised the wholesale price of Mustargen roughly tenfold and that of Cosmegen even more, according to several pharmacists and patients."

What is invidious about this particular example is that many of the arguments that justify drug company costs aren't here. The drug is more than sixty years old, so there has been no cost to its development. There is no need to develop a manufacturing facility because one already exists.

This is not, of course, only a US thing. The increasing success of medicine and, in particular, the cost of drugs is pinching the limited resources of the NHS. As the Sunday Times said the other day We can control it, but can we afford it.

The problem of affording cancer care is only going to get worse.