Wall Street Journal Review of The End of Medicine

BOOKSHELF
The Art of Navigating Arteries
Andy Kessler wonders why medicine can't be more like computers.

BY WILLIAM TUCKER
Tuesday, July 18, 2006

Health care has always been the White Whale to Silicon Valley entrepreneurs. Recall "The New, New Thing" (1999), in which Michael Lewis chronicled venture capitalist Jim Clark's efforts to upend the status quo with Healtheon (now part of WebMD). Mr. Clark hoped that his new company would smooth down the rough inefficiencies in health care by digitizing medical records and joining doctors, patients and payers in a streamlined--and online--system. The verdict is still out; the results, so far, have been modest.

Mr. Kessler sets out on an odyssey...he gets it all down with Jack Kerouac-like authenticity

Andy Kessler has similarly grand ambitions, although without the venture-capital part. "Why," he asks, "can't medicine scale the way computers do?" In information technology everything can be reduced to chips, which keep getting smaller and cheaper, making costs go down. In medicine, everything works in the opposite way. Costs keep going up. Why?

To answer the question, Mr. Kessler sets out on an odyssey that takes him from Stanford to Harvard to Memorial Sloan-Kettering in New York to the Fred Hutchinson Cancer Research Center in Seattle, with a lot of stops in between. A former financial analyst who chronicled his Wall Street adventures in "Running Money," Mr. Kessler has the spirit of an inquisitive iconoclast and the manners of a standup comedian. His investigation is conducted in a bumptious first-person style that can be entertaining, if a little exhausting. By the time he is finished, though, he has made a serious point: Even discounting for hyperbole, we may eventually be able to imagine the "end of medicine."

The problem right now, as Mr. Kessler sees it, is that we fight the "big three"--cancer, stroke and heart attack--with treatment rather than early detection. Cancer cells and blood-vessel plaque can be handled much more easily in the early stages, but we spend most of our money on the later ones. More than 80% of health-care dollars are paid by insurance companies and the government, and neither is especially interested in detecting disease when it first appears. Doctors, regulators, researchers and payers of all kinds are locked into what Mr. Kessler calls--a bit ungenerously--the "cholesterol and cancer conspiracies."

A complicated system of mutual dependency distorts the incentives. "The FDA is like the FCC and Big Pharma is like the regional Bells" is what Mr. Kessler hears from Don Listwin, a former Cisco executive who now heads the Canary Foundation, a Silicon Valley-based effort to promote preventive medicine. In other words, in medicine as in telecom, the big players end up exploiting regulations more than opposing them, if only to preserve their monopolies. The Food and Drug Administration--understandably but narrow-mindedly--wants "cures" for cancer and other diseases. Thus tens of thousands of chemicals are screened, only a handful make it even to Phase I trials, and by the time a new drug is approved a billion dollars has been spent. Even then the new drug may help only 10% of patients.

Yet if someone were to invent a device with a wide, preventive usefulness--say, a nanotech implant that would spot the proteins that indicate the first minute presence of cancer--it would have to go through the same process of billion-dollar testing. Since the government and insurance companies are reluctant to add anything to their repertoire of coverage--and since such a device would be targeted at the much broader pool of people who are not sick--research might well stall in its earliest phases for lack of reimbursement-funding.

Yes, it is possible to object that doctors and insurance companies do engage in preventive medicine. Don't they urge annual checkups? Don't insurers even pay for them? But that's not the kind of preventive medicine Mr. Kessler is talking about. He means devices that bypass doctors completely. There are diagnostic tools that work as easily as a home pregnancy test. They're just hard to access.

In one hilarious sequence, Mr. Kessler recounts trying to draw his own blood sample, in the hope of checking his cholesterol. But clinics won't draw blood without a doctor's orders. Drugstores think you want the syringe to shoot heroin. Unless you want to just gouge your own finger, you're in the clutches of organized medicine. Imagine how tightly it grips something a bit more sophisticated.

Yet diagnostic technology is taking off--and that's the crux of Mr. Kessler's book. Tomography--that is, three-dimensional imaging--is slicing and dicing the human body (figuratively speaking) almost down to the cellular level. Exploring the inside of someone's carotid arteries is like playing a video game. In one amazing scene in "The End of Medicine"--it still doesn't quite seem real--Mr. Kessler describes a "face off" between five rival 3-D modeling systems at the seventh annual Multi-Detector Row Computed Tomography Symposium in San Francisco.

"I was transfixed," he writes. "This guy was zooming through someone's brain like it was . . . level 60 in World of Warcraft. . . . The place went crazy. This was repeated on each of the workstations by different doctors to often thunderous applause. I had a mild headache from all the excitement."

Behind it all, of course, is medical know-how of an esoteric sort. "But then there are these integrins--adhesion molecules," one doctor tells Mr. Kessler. "This one specific integrin, alphavbeta3, is specifically expressed on proliferating endothelial cells and tumor cells that are forming new blood vessels. That's how we catch them, we find these integrins." Mr. Kessler follows this talk although he seems, at times, as baffled as the reader. Yet he gets it all down with Jack Kerouac-like authenticity.

 

 

Mr. Kessler's ultimate vision is that of a brave new world where hundreds of antibodies attached to carbon nanotubes monitor our blood every day--every minute?--for early signs of artery clogging or cancer. Then, if need be, 3-D imaging can zero-in on offending cells, holding them in the target for destruction by radiation or other proteins. People won't live forever, but they will be much healthier and happier as they get older.

The more Mr. Kessler looks at the promise of medical technology, the more it reminds him of the early days of Silicon Valley, when "capital funded a bunch of different approaches, experiments raged through the night and innovation exploded all over the place." Now, if the FDA would only allow entrepreneurs to track down those integrins.

Mr. Tucker is a writer in Brooklyn, N.Y.

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