Healthcare NBIC

Google Health 2018: Best -- and Worst -- Case Scenarios

On the face of it, Google Health released this month in beta is just another personal medical record system similar to a hundred others including Microsoft's HealthVault. But Google has designed a specifically open health record: providers, payers and all kinds of service companies can use the published Application Programmer Interface to link their data to your Google health file.

Since Google is not a healthcare provider, the privacy restrictions of HIPPA, the Health Insurance Portability and Accountability Act of 1996 don't apply. Health IT security guru Fred Trotter describes why this is a good thing, and we went brainstorming to see how open architecture might affect wellness, sex, eldercare, insurance and other health concerns.

Read Google Health 2018: Best Case Scenarios.

Read Google Health 2018: Worst Case Scenarios.

The glass is half-full or half-empty. Add your comments below, and or a different comment perspective, see the thread on these articles at Slashdot.

Transgenic Chickens Manufacture Expensive Drugs

Here's a follow-up to our popular post about transgenic pigs makingdrugs in their milk. Oxford Biomedica and Viragen, Inc. yesterday announced that they have produced two therapeutic proteins in the whites of transgenic chicken eggs. Publishing in the Proceedings of the National Academy of Sciences of the United States of America (PNAS), the companies describe how the "OVA technique" created two substances: miR24, a monoclonal antibody for advanced malignant melanoma, and interferon beta-1a, a multiple sclerosis treatment currently marketed under two competing brand names, Avonex® (Biogen Idec) and Rebif® (Serono).

A Reuters article outlines the promise of animal factories for pricey therapies -- Avonex therapy costs $850 per month and can stretch on for years. Outsourcing pharma to the barnyard could make important drugs affordable to all.

U.S. Healthcare Spending: Good News/Bad News

"It doesn't matter how much money you have, as long as you have your health," they say. That's why it makes sense that the richest country in the world spends the most on healthcare. According to an article in the journal Health Affairs, the good news is that U.S. healthcare spending growth slowed in 2005 to 6.9% annually. The bad news is that total spending reached $2 trillion per year, 16% of the Gross Domestic Product (GDP), almost $6,700 per person for each of the 300 million Americans.

Following the change in control of the House of Representatives and the Senate in the last election, analysts like Jill Gardiner writing in the New York Sun report renewed interest in national political circles for some kind of national health insurance. Citing recent initiatives from New York's Senator and likely Democratic presidential contender Hillary Clinton and incoming Governor Elliot Spitzer, Massachusetts' former governor and Republican presidential aspirant Mitt Romney, and California's Governor Arnold Schwarzenegger, Gardiner notes that the latest policies bring business needs into the debate: companies' healthcare costs now amount to significant proportions of overhead.

A national plan like Canada's or England's won't do. Gardiner quotes Dr. David Gratzer of the Manhattan Institute who noted that coverage is more available than is regularly assumed. A third of the 46 million Americans who are uninsured are already eligible for government-subsidized insurance but have not signed up; another third earn $50,000 or more. "That seems to be a crisis in signing your name to a piece of paper, rather than a crisis in coverage," Gratzer grumped.

Healthcare spending is likely to become the big domestic policy topic of the 2008 presidential election campaigns. With any luck, we'll get some comprehensive discussion of the issues in the next 22 months.

Dark Side of the Internet: Pro-Anorexia Sites

We're always seeking to enhance healthcare choices under the assumption that the more information we have, the more control over our health we exercise, the better off we'll be. Some of the choices we make are questionable: following fad diets or quack cures; modifying our bodies with tattoos, implants or sex changes; leading sedentary lives filled with trans-fats and sugared colas. Western society tolerates the odd choices, preferring more information rather than less, but sometimes information can kill us.

A pilot study published in the journal Pediatrics, "Surfing for Thinness", examined adolescents use of web sites that promote anorexia and bulimia. (These sites are often called pro-ana and pro-mia sites. See one logo at left.) The study estimates that there are approximately 500 pro-eating disorder (pro-ED) web sites, outnumbering the anti-ED/pro-recovery sites about 5 to 1.  Like the health-interested web user population at large, up to two-thirds of adolescent girls surf the web for health information, nearly half looking for ways to lose weight. In a survey of teens, 96% said they learned new weight loss or purging techniques from the pro-ED sites. (The study also noted that some web sites also influence drug use in youth and promote anti-health behaviors such as self-injury, suicide, and smoking.)

Obviously, parents have to be aware of their kids' Internet use and be alert to signs of eating disorders in general. At About.com, Dr. Vincent Iannelli offers some advice to parents. But after the child is grown, there's no way to stop her or him from surfing sites that promote bad health. Authorities in Madrid recently shut down a pro-anorexia web site as a hazard to children, but the free-wheeling information economy of the global Internet won't always be there to save us. We'll have to be sure we make the right health choices.

Cord Blood Bank Accounts Suddenly Look A Lot Smarter

Yesterday's on-line publication in the journal Nature Biotechnology of the paper "Isolation of amniotic stem cell lines with potential for therapy" has created a media firestorm with the announcement that stem cells have been identified in the human placenta. The multipotent amniotic fluid-derived stem cells (AFS cells) are described as nearly as powerful as pluripotent embryonic stem cells, but they can be harvested from ubilical cord blood either in or ex utero -- no embryos are destroyed in the process. AFS cells are easy to grow in the lab, and unlike embryonic cells, they don't develop the benign tumors called teratoma.

In the seven year study, scientists at the Wake Forest Institute for Regenerative Medicine and Harvard Medical School led by Dr. Anthony Atala were able to grow AFS cells into muscle, bone, fat, blood vessel, nerve and liver cells. Since the late 1980s, doctors have transplanted the hematopoietic stem cells found in umbiical cord blood to treat blood diseases. Now the AFS cells promise a wider range of therapies in the future.

The early buzz in the general press focuses on the non-destructive harvesting of AFS cells. The contentious ethical issues surrounding destroying embryos for research have been rendered moot, it would seem. But another aspect of the new findings shows how science develops faster than the policies we make to manage it.

PUBLIC VS PRIVATE CORD BLOOD

There are two kinds of cord blood banks that capture and store umbilical cord and placenta blood for transplant. Public cord blood banks receive altruistic donations of material that is made available to anyone who needs it, just like whole blood and bone marrow banks. Private cord blood banks charge new moms and dads several thousands of dollars to collect and store their child's placental blood for their family's future private use. In the last ten years, the  American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the United Kingdom's Royal College of Obstetricians and Gynaecologists has discouraged private banking, and authorities in France and Italy ban it outright.

The debate is well presented in last year's PLoS Medicine article "Can Routine Commercial Cord Blood Banking Be Scientifically and Ethically Justified?" The case against private umbilical cord blood (UCB) collection comes down to five points:

1. Public donations are adequate to treat most blood diseases in which rejection of the transplanted  cells is not a problem.
2. Collecting and storing private material is logistically difficult.
3. The hard-sell of commercial cord blood services to new parents at a vulnerable time is coercive.
4. We can't be sure private companies will maintain high standards or even stay in business long enough to deliver needed transplant blood.
5. "Other uses for UCB remain speculative since it is unclear whether non-haemopoietic stem cells are present in sufficient numbers for use against degenerative conditions."

Now, "other uses" are a lot less speculative: other kinds of stem cells are in UCB. Concerned parents only get once chance to collect umbilical cord blood, and even at $2,000 per child, it seems like a cheap spare parts kit if the new AFS cells turn out to be useful in medical therapies in 20 or 50 or 100 years when the kid or some other family member needs it.  To heck wih a college account, put away some stem cells for a rainy day.

The "Ashley Treatment": Hard Choices for Life Enhancement

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"I think most people, when they hear of this, would say this is just plain wrong," Brosco said. "But it is a complicated story, and when you get into this issue, you can understand the difficulties.

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That's Miami pediatrician Jeffrey Brosco talking about the case of "Ashley," a nine-year-old girl with static encephalopathy, severe brain damage that leaves her bedridden, unable to roll over or sit up by herself, fed by a tube. Her parents say she hasn't shown material in mental ability since she was three months old. They call her a "Pillow Angel" because she tends to stay where they put her -- and because they love her deeply.

What makes the story complicated is the treatment Ashley's parents designed for her, in consultation with doctors and ethicists at Seattle Children's Hospital and Regional Medical Center. In July 2004, they removed her uterus so she wouldn't mentruate or have cramps; they removed her early breast buds so she wouldn't have fully developed breasts; they administered high dose estrogen therapy to attenuate growth; and they removed her appendix to avoid a potential appendicitis that she wou;dn't be able to tell anyone about. The result is that she will remain 4 ft 4 in tall and about 75 lbs for the rest of her life, making life more comfortable for her and making it easier for her parents to care for her at home.

Ashley's doctors Daniel Gunther and Douglas Diekema broke the story in an article in the AMA journal Archives of Pediatric and Adolescent Medicine titled Attenuating Growth in Children With Profound Developmental Disability: A New Approach to an Old Dilemma. In the same issue, an editorial by Dr,  Jeffrey Brosco (quoted above) and Dr. Chris Freudtner  explored the ethical dilemma and asked four questions: Will it work? Is it unacceptably unnatural? Could it be misused?  And -- tellingly -- does it detract from the argument for more spending on home health care?

An on-line Reuters story and MSNBC message board ignited the debate, and yesterday a syndicated LA Times story by Sam Howe Verhovek expanded the discussion on-line, in print and finally on TV (after the g-d pre-roll ad).

Life enhancement innovations like cosmetic neurology, 20-15 LASIK, non-therapeutic abortion, body modification and other elective surgeries are an inevitable part of medical care in a free society. Enhancing the life of your child should be included in that list. Ashley's parents have published a heart  rending anonymous blog of supreme, clear-eyed love and honesty called The Ashley Treatment. They describe how they came to the decision, explain the details in-depth, and try to cope with some of the knee-jerk vilification they've received since the story got out. To them, it was an easy decision: they wanted their daughter to be happy. In the process, they've advanced an important discussion in healthcare immeasurably.

Three Inventions from Fischell

Award-winning medical inventor and philanthropist Robert Fischell spoke at the TED (Technology, Entertainment and Design) conference about three disruptive healthcare innovations he's developing: an implantable early warning system for heart attacks, an electro-magnetic dampener for migraines, and a neurostimulator implant for preventing epileptic seizures.

(Click   to start.)

Fischell is responsible for the first implantable insulin pump, the rechargeable pacemaker, and highly flexible coronary artery stents. A physicist and engineer with three sons -- one cardiologist, one physicist and one MBA  -- as collaborators, he's the kind of natural-born inventor who takes obvious pleasure in making things work.

Reverse Genetic Engineering

Scientists at the University of Utah have retrogressed the genetic development of a mouse, reconstructing a half-billion-year-old gene by combining key portions of two modern mouse genes that descended from the archaic gene.

The study focused on so-called Hox genes which direct the actions of other genes during the development of an animal embryo. Early animals had 13 Hox genes, but sometime between 530 million and 480 million years ago each Hox gene split into four, so 13 became 52. Duplicate Hox genes later either mutated in a way that proved useful, or vanished because they were redundant, so today in humans and other mammals there are 39 instead of 52 Hox genes. Researchers Mario Capecchi and Petr Tvrdik say that by combining critical portions of two later genes, Hox1a and Hox1b, they effectively recreated a gene with the function that the original Hox1 performed more than 530 million years ago.

The ability to reconstruct an ancient gene from descendant genes raises the possibility of a new type of gene therapy in which a portion of a related gene could be inserted into a disease-causing mutant gene to restore its normal function and cure the disease, Capecchi and Tvrdik say.

The study titled Reversal of Hox1 Gene Subfunctionalization in the Mouse was published in the journal Developmental Cell. A press account describing the work, with before-and-after photos of mice, is posted at the University of Utah web site.

Walmart's Loss Leaders: First Beyonce, Now Prozac (fluoxetine hydrochloride)

In the new year, Walmart now offers a $4 prescription price on more than 300 generic drugs in all Walmart controlled pharmacies in 49 U.S. states. As we saw in the previous posts Walmart's Tough Choices and  Walmart Medical Clinics, disruption is bound to happen as 21st Century business comes to grips with the 20th Century way we have of handling healthcare.

The pricing power of Walmart and its willingness to discount deeply to get customers into the store has already transformed the music industry. The list price on Beyonce's second solo album B'day is $18.98, but you can get it at Walmart for $11.98. (You can alternately download the album's three good tunes -- including the currently hot $3.49 single Irreplaceable -- for just 88 cents apiece.) Now they're selling the generic form of Prozac for just $4 for a month's supply versus the $33 average  branded price.

In the study Market power in music retailing: the case of Wal-Mart published in the academic journal Popular Music and Society, Mark A. Fox analyzes how Walmart's discounting changed the record business by highlighting only sure-fire bestsellers. More ominously, he describes the content decisions Walmart forces on artists: no cover art or lyrics that are too sexy, no songs denigrating Walmart, and no albums with Parental Advisory stickers.

Walmart's ability to drive down the cost of genercic drugs is a good thing. But in the pharmaceutical context, questions arise: "How does Walmart decide which generics to offer at low cost?" I didn't see a Contraceptive category, for example, although in the Hormones category medroxyprogesterone AC is listed in 2.5, 5 and 10 mg dosages. "What influence does commerce have on medicine?" There are lots of cardiac and diabetes offerings, but only one generic cancer drug and two Parkinsons generics. Chronic patients with repeat business seem to get a better break than short-timers who get cured or die. "How will Walmarts' near-inevitable monopsony power --  its control over suppliers -- influence pharma companies' choices in drug discovery, packaging and dosage. " Walmart prefers Splenda, so Coca-Cola had to change its new product to use Splenda. When it comes to medicine the potential for nutty conspiracy theorists is astounding.

An Extra B in NBIC in the New Year

Since launching this site in  May of 2005, I've written about the NBIC categories of nano-, bio-, info- and cognitive sciences, but among the most disruptive innovations in healthcare are the business models: healthcare consumerism, practice economics, e-commerce, emarketing and insurance. While new science and technology is an important part of the story, the practical consequences of economics, demographic, culture and expectations is, too. I won't add another B into NBIC, but we should take care to notice the business side of the changes taking place in the field.  --Jack Powers