Fourth of Four Parts…
The American Way of Medicine
In the third installment of this four-part series, we compared fighting disease to fighting a war. In both cases, the goal should be to win.
And so as we think about mobilizing to win the war against disease, disability, and premature death, we might start by thinking about how we’ve won our wars in the past.
In particular, we might recall a 1973 classic of military history, The American Way of War, by Russell Weigley, a professor of history at Temple University, who also taught at the Army War College.
Weigley’s ultimate lesson was that the US didn’t always have the best soldiers, or the best generals, but it almost always had the most industrial might. And so that’s how we won: by avalanching the enemy. As Weigley explained, we used “a strategy of attrition” when necessary, and “a strategy of annihilation” when possible.
In World War Two, for example, we built 27 aircraft carriers, 60,000 tanks, and 300,000 airplanes–along with 12.5 million rifles and carbines, and 41 billion rounds of ammunition. That’s how you annihilate.
So without taking anything away from the courage and fortitude of America’s fighting men, we can observe that it was this massive advantage in materiel that enabled us to win the war while suffering “only” 400,000 dead. Meanwhile, other combatant countries were suffering millions of fatalities, even tens of millions.
Indeed, Uncle Sam’s typhoon of steel enabled us to get over some deficiencies in our war production. As we discovered in the European theater of operations, the American M4 Sherman tank was much inferior to the German Tiger II tank (as anyone who saw the opening tank battle in the recent Brad Pitt movie, Fury, was reminded). And yet the Shermans outnumbered the Tigers by more than 100:1. As they say about war, quantity has a quality all its own.
In addition, the army of Eisenhower, Patton, and Bradley deployed thousands of tank destroyers, that is, mobile artillery capable of direct fire in a flat trajectory.
Also, the Americans had abundant ammunition, spare parts, fuel, and, of course, air superiority. Confronting such advantages, even the best enemy soldiers were doomed. The German “panzer ace,” Michael Wittmann, for example, had destroyed hundreds of Soviet tanks in three years of fighting in the East, and yet in 1944, when he and his Tiger II were transferred to fight the Allies in the West, he and his crew were killed within weeks.
And oh, by the way, the United States also built, and used, the atomic bomb. So that’s the American Way of War: Clobber ‘em.
So now let’s turn to the American Way of Medicine. As with the US military, the key idea of US medicine is, Spend a lot of money to produce a lot of stuff.
Indeed, in 2016, our total health expenditure was $3.36 trillion; that’s a bigger number than the GDP of all but four other countries.
Is the US healthcare system sloppy and wasteful? Sure it is. Do people sometimes fall between the cracks and suffer unnecessarily painful and tragic fates? Sadly, yes. Do some companies, hospitals, and doctors reap unfair windfall profits at the expense of the rest of us? Affirmative.
Yet at the same time, our system is robust. We can pause to note that international comparisons on health and longevity are tricky, because some Americans have a propensity to eat too much, drink-and-drug themselves too much, and get shot too much.
Still, there’s a reason why people come here from around the world to be treated. The fabled health complexes of America—including Johns Hopkins, the Texas Medical Center, and Cedars Sinai—are rich in talent and technology, and so they are medical meccas for the world.
Indeed, according to one study, 14 million foreigners came to the US for medical treatment in 2016, bringing in with them at least $45 billion. By contrast, only about 1.4 million Americans went abroad for treatment. So if the ratio of inflow to outflow is 10:1, we must be doing something right.
It should be pointed out, of course, that the distribution of healthcare resources around the country is not equal. And here, the glaring injustice is toward the middle class, not the poor. As we know, the poor have Medicaid, which spent nearly $600 billion last year, or almost $7500 per beneficiary. In addition, since, under federal law, hospital emergency rooms can’t turn away an incoming patient, they have emerged as, in effect, a major component of indigent care. Hospitals can recover some of that cost through a federal program, and yet even so, in 2015, they lost $35.7 billion in “uncompensated care.” And of course, private charity, both tabulated and untabulated, donates many billions more.
In the meantime, a middle-class person in “flyover country” might have access to neither a world-class hospital, nor to federal largesse. That’s doesn’t seem fair.
So perhaps we should think of a better approach, so that all Americans, regardless of economic class, can get the benefits of the medtech cornucopia that those blessed by money and geography already have access to.
Indeed, perhaps we could go even further: Let’s declare that it’s a national objective to improve the life prospects of everyone by concentrating on that which most starkly diminishes our life prospects—that is, disease, disability, and premature death.
And of course, let’s learn from our own history, heavy as it is with technological solutions: Indeed, in the spirit of the bazooka, the B-29, and the Bomb, let’s develop a plan for overkilling the killers we confront. That is, after all, the American Way.
An American Cure Strategy
Paradoxical as it might seem, our exploration of an American Cure Strategy might begin with a Prussian. In his 1832 classic, On War, Carl von Clausewitz addressed matters of strategy in ways that stretch far beyond combat. That is, what he wrote applies to almost any critical situation: “The best strategy is always to be very strong, first generally, then at the decisive point.”
In other words, build up, prepare, and then make your move. And yet even if the logistics of mobilizing are necessarily complex, Clausewitz continued, the guiding idea must be simple, or act least simply stated:
Simplicity in planning fosters energy in execution. Strong determination in carrying through a simple idea is the surest route to success. The winning simplicity we seek, the simplicity of genius, is the result of intense mental engagement.
Hence the need for an articulated strategy, so that a complex plan can be broken down into its parts, such that each participant knows his or her role, enabling the plan to proceed:
The talent of the strategist is to identify the decisive point and to concentrate everything on it, removing forces from secondary fronts and ignoring lesser objectives.
We can quickly see that the key issue is the quality of leadership. And since, as we know, good leadership has been substantially lacking in America over the last few decades, we might learn from the better leaders of the past.
In the 20th century, for example, our 32nd president, Franklin D. Roosevelt, established the gold standard of war leadership. Even before Pearl Harbor, the commander-in-chief was seeking both to mobilize American industry and enlist American allies. And yet he never neglected the vital backbone of his efforts, the American middle class. As he said early on in the fighting, on Labor Day, 1942:
The people who live by the sweat of their brows have risen mightily to the challenge of the struggle. They have given their sons to the military services. They have stoked the furnaces and hurried the factory wheels. They have made the planes and welded the tanks, riveted the ships and rolled the shells. Production of war materials here is now the greatest in our history, but it is not yet enough. It will be greater still.
We might note that this is how you win a war: You inculcate an “all in” spirit that binds a nation together and inspires it to heroic achievements, both of arms and of arms manufacture.
Late in the war, even as he himself was near death, FDR saw that the same model, that of mobilized production, could be applied to postwar pursuits.
In a November 17, 1944 letter to Vannevar Bush, a corporate executive who served the war effort as director of the Pentagon’s Office of Scientific Research and Development, FDR outlined a bold vision:
The information, the techniques, and the research experience developed by the Office of Scientific Research and Development and by the thousands of scientists in the universities and in private industry, should be used in the days of peace ahead for the improvement of the national health, the creation of new enterprises bringing new jobs, and the betterment of the national standard of living.
That is, the same scientific know-how that gave us wonder-weapons could now bring forth wonderful tools of peace—in other words, perpetual R&D aimed at national needs. And here we might pause to note that a century before Clausewitz had made the same point: “We need a philosophy of strategy that contains the seeds of its constant rejuvenation—a way to chart strategy in an unstable environment.”
Meanwhile, back in ’44, FDR had health very much on his mind; he asked the Pentagon chief specifically:
With particular reference to the war of science against disease, what can be done now to organize a program for continuing in the future the work which has been done in medicine and related sciences? The fact that the annual deaths in this country from one or two diseases alone are far in excess of the total number of lives lost by us in battle during this war should make us conscious of the duty we owe future generations. [emphasis added]
Okay, that was then. Today, the tactics might have evolved, but the underlying strategic idea ought to stay the same; as Clausewitz said, Identify the decisive point and concentrate everything on it.
The First Targets
And so we come back to where we started, in Part One of this series: the issue of pharmaceutical drugs. Drugs and medicines are not the only way to cure disease, of course. We should all take care of ourselves; after all, the basics of a good diet, adequate exercise, and a healthy lifestyle are cheap, if not free.
And yet even the “best” people are afflicted with deadly diseases that make a mockery of do-it-yourself treatments. When Apple CEO Steve Jobs, for example, was first diagnosed with cancer in 2003, he tried to treat it with acupuncture and other New Age-type “alternative” therapies. Only later, after the cancer had spread, did he seek real treatment and surgery, including a liver transplant. And yet by then, it was too late; he died in 2011, at the age of 56.
In the words of Barrie R. Cassileth, founder of the Integrative Medicine ServiceMemorial Sloan-Kettering Cancer Center:
He had the only kind of pancreatic cancer that is treatable and curable. He essentially committed suicide.
The point here is not to mock alternative treatments, or to gratuitously make fun of new medical ideas of any kind. Instead, the point is to emphasize that the patient needs to be mindful of what works.
Sometimes, as we know, the best treatment is an old treatment, repurposed in a new way. For example, aspirin has been around since the late 19th century, and it’s always been effective as a pain-killer. Yet more recently, we’ve discovered that it helps against heart disease. And the same medicinal qualities can be found in a natural substance, garlic.
Still, sometimes, none of the available treatments, new or old, are effective. And so then all of us, individually and collectively, ought to put on our thinking caps and figure out better methods.
President Trump is mindful of the reality that we need new thinking. As he said in his meeting with pharmaceutical company executives at the White House on January 31:
New drugs have led to longer, healthier lives—we all know that—but we have to do better accelerating cures.
Indeed, the cause of accelerating cures is a worthy mission for a great country. And we can add, humanitarian considerations aside, the effort would probably pay for itself. As Sen. Ted Cruz observed during his February 7 CNN debate with Sen, Bernie Sanders:
The four most devastating diseases [are] heart disease, Alzheimer’s, diabetes and cancer. We ought to be investing everything we can to cure those diseases. Just curing cancer, an incredible achievement, would save $50 trillion and countless lives across the globe.
We might pause over that number, just for cancer: $50 trillion. To put that another way, how much would we be wise to spend now, in order to save $50 trillion later?
Of course, many Americans, perhaps most, will say that the pharma companies aren’t to be trusted with such an important mission. That is, it’s widely thought that they will never seek to make drugs that heal because they prefer to make drugs that merely palliate—that is, “hooking” people on a lifetime of treatment for a chronic condition.
So here’s where we see the value of a conscious national strategy: If we are fighting a war against disease, then we want to win that war. And as World War Two, as well as other victorious wars have shown us, the way to win a war is to fully mobilize the population, so that everyone feels that their contribution is valued and yes, that their sacrifice is necessary. That’s the essence of strong and durable national resolve.
So now we can begin to see the outlines of what a Cure Strategy would look like.
For the sake of medical innovation, we should offer tax incentives, deregulation, and big-dollar X-Prizes for needed discoveries. We might also explore new ways of financing the life-saving drugs we need, such as new kinds of private-sector-based bond-financing.
In the meantime, it makes no sense to devote new money to medical research and cures if it is simply to be chewed up by the bureaucrats at the Food and Drug Administration, or swallowed whole by the trial lawyers.
Indeed, we might further ask ourselves: What would happen if we created a medical enterprise zone somewhere in the US? What if we had a Las Vegas, or Hong Kong, for cures? Or better yet, what if the whole country were a medical cure zone?
So yes, we should have a national and comprehensive approach. What Clausewitz said of strategy in war— Strong determination in carrying through a simple idea is the surest route to success—is just as true for a strategy of cures.
Yet there is one more thing to worry about. And it’s not a small thing.
A Three-Part Solution to the Thorny Issue of Drug Pricing
As we have seen, a key part of any viable national strategy is the idea of mutuality. That is, if we are all in this together, to help each other win, then we can’t be ripping each other off. And that dictum applies to pharmaceutical companies. As President Trump also said to the pharma executive on January 31:
US drug companies have produced extraordinary results for our country, but the prices have been astronomical. . . . We have to get the prices down.
To that end, here are the quick outlines of a possible framework for drug prices that might everyone feel as we’re all in this together. Let’s divide drugs into three categories: “Generally Accepted,” “Newly Innovative,” and “Non-Essential.”
Generally Accepted (GA) is just that: The drug has been researched, developed, and approved by the FDA. As such, a GA drug should be deemed to be litigation-proof. That is, if the government has decided that it’s safe, then some jury shouldn’t be able to decide otherwise and levy a huge penalty on a law-abiding company. If a drug is belatedly discovered to be unsafe, then by all means, we should pull it off the market, but let’s not loot the firm that made it in good faith.
In return for this protective framework, GA drugs would be subject to utility-style price regulation. In other words, the drug maker would be entitled to a fair rate of return—but no more.
Meanwhile, GA makers would be free to sell their drugs abroad for whatever the overseas market would bear. (This would, of course, create the phenomenon of “reverse reimportation,” since some drugs, at least, might now be cheaper in the US than elsewhere; that’s one of many issues that would have to be ironed out.)
Newly Innovative (NI), too, is just what it sounds like: NI drugs would be the fruit of bet-the-company, shoot-the-moon efforts. As mentioned, incentives of various kinds can help, even as the overwhelming emphasis would be on encouraging visionaries, investors, and companies to use their own money to do new things and take big risks.
NI drugs would still have to be approved by the FDA (but tested for safety only, as opposed to the FDA’s current policy of safety and efficacy—efficacy being an unknown unknown in too many cases).
So we can see, the NI category would be, by design, something of a wild west, both scientifically and entrepreneurially. Still, as needed, the political system would stand ready to step in to stop price-gouging. Were we ever to find, for example, a cure for cancer, we would want everyone to have access to it, even as the developer was handsomely, if not extortionately, rewarded.
Non-Essential (NE) is another self-evident category. For those whose ambition is to create a better kind of botox or Viagra, well, they are welcome to do so. But since there’s no real public-policy purpose being served, we can leave them in the current system, pretty much as it is.
So we can see: This Cure Strategy Framework would be guided by three key objectives: First, we need new cures. Second, we need fair prices. Third, we need a full-flowing “pipeline” of new curative drugs.
Indeed, a Cure Strategy is vital, because in addition to the familiar killers, the next mass-killer could be looming on the horizon. Just in the past few weeks, we’ve seen many scary headlines; here’s just a smattering: “Alarming’ superbugs a risk to people, animals and food, EU warns,” and “Malaria superbugs threaten global malaria control, scientists say.” And this, close to home: “Biorisk: Doomsday Bug, Resistant to Every Drug, Found in LA.”
Yes, the war against disease is, in fact, a war. Diseases are trying to kill us, and they are constantly evolving new ways of dealing death. So that’s why we, as a nation, should mobilize to strike first.
All our history tells us that if we do that, true to our own tradition, we can win.