Start the Revolution Without Us

Well, as usual, there’s a lot going on in healthcare.  There’s the (potential) Amazon – One Medical acquisition, the CVS – Signify Health deal, and the Walmart – United Healthcare Medicare Advantage collaboration.  Alphabet’s just raised $1b.  Digital health funding may be in somewhat of a slump, but that’s only compared to 2021’s crazy numbers. Yep, if you’re a believer that a revolution in healthcare is right around the corner, there’s a lot of encouraging signs. 

Credit: about digital health

But I was in a Walmart the other day, and my thought was, these people don’t look like they care much about a revolution in healthcare. In fact, they don’t look like they much care about health generally.  That’s not a knock on Walmart or Walmart shoppers, that’s an assessment about Americans’ appetite for changes in our health care. 

That’s not to say we like our healthcare system.  A new AP-NORC survey found that 56% felt that the US did not handle healthcare well (curiously, 12% thought we handled it extremely/very well – huh?).  Prescription drugs, nursing homes, and mental health rated especially low.  We’d like the government to do more, but not, it would seem, if it means we pay higher taxes.

Credit: the Simpsons

Much of what is wrong is our own fault. We know that we eat too many processed foods, that the food industry scientifically preys on us to target our weaknesses for fat, sugar, and salt, that we’d rather sit than drive and drive than walk, and that we are poisoning our environment, and, in turn, ourselves.  Given a choice between short term benefits versus long term consequences, though, we’ll eat that Oreo every time, literally and metaphorically.

What started me down this grim train of thought, oddly enough, is a new article in The Atlantic by Jennifer A. Doudna: “Starting a Revolution Is Not Enough.”   Dr. Doudna’s focus was, naturally, on the CRISPR revolution, but some of her points apply more broadly.  

Dr. Doudna is justifiably proud of all that CRISP has already accomplished, but:

I also feel a continual sense of urgency: Are we dreaming big enough? Moving quickly enough? I think back to the advent of the cellphone—another groundbreaking technology in our shared memory. For those of us lucky enough to have experienced it, the untethering of communication from a landline was a seminal moment. But who could have predicted that this once niche and luxury technology would become so ubiquitous as to outnumber the human population, creating new economies and changing the way we live?

That’s my fear about all of the supposed revolutions in healthcare: I’m pretty sure we’re not dreaming big enough, and we definitely aren’t moving quickly enough. 

With CRISPR, Dr. Doudna believes:

Ensuring that CRISPR reaches its full potential for clinical applications and beyond will require an even higher level of intentional building with diverse and dedicated collaborators. Governments, universities, and investors will need to make significant and sustained investment in cutting-edge science at labs and at biotechnology companies, as well as investments in infrastructure and manufacturing to ensure that this work is scalable.

All that could also be talking about AI, nanotechnology, robotics, VR, or any of the other long list of innovations that have the potential to revolutionize healthcare.  We’re a long way from finishing the science, much less bringing it to play into our healthcare system and, more importantly, into our everyday lives.

Credit: Emerging Europe

Technology is not enough. In a New York Times op-ed about the Amazon-One Medical acquisition, Libby Watson asserts:

Any company claiming its innovation will revolutionize American health care by itself is selling a fantasy. There is no technological miracle waiting around the corner that will solve problems caused by decades of neglectful policy decisions and rampant fraud.    

Similarly, Dr. Doudna worries about potential abuse with CRISPR: “How do we ensure that those in need have access when people or companies with money and power cut in line?”  That is, unfortunately, how our healthcare system has worked in recent decades, and perhaps always. They will not accede to change easily. 

It’s worth remembering that most revolutions fail.  They start too soon, they don’t have enough popular support, they face vested interests that are too firmly entrenched, or their timing is simply off.  Americans are proud of our own revolution, but too often we forget that most of the colonists did not support it, that we needed strong allies, that a few key leaders were pivotal, and that it took both some luck and some blunders from our opponents to ultimately succeed.

In healthcare, we have to remember that, while a majority of us aren’t happy with our healthcare system, only a minority of us are pushing for big changes.  Only a minority of us are actively engaged in our health on a daily basis. We say we’re unhappy about costs but what we really mean is that we want someone else to pay the costs. We grumble about how expensive they are but don’t really want our doctors or local hospitals to take revenue hits.  We hate pharma and health insurance companies, but only until we need them. 

The vested interests in our healthcare system aren’t you and me; they’re the people who are first in line for care and for whom money is never any issue. They’re the medical/industrial complex, including those local doctors and hospitals, who profit from the existing system. We’re not going to have a revolution without them being disrupted, and few of us are quite ready for that. 

A revolution in healthcare isn’t our existing system but with some newer technologies; we’ve been incrementally doing that for a long time.  A revolution in healthcare would actually look different, would deliver care differently, would impact our health differently, and hopefully would be financed differently. 

As Dr. Doudna says, in reference to CRISPR but with application to other revolutionary technologies: “When facing progress of this magnitude, the first step toward adoption must be societal buy-in.”  No, we’re not quite there yet.  Worse yet, I’m not quite sure what will get us there.

There’s a famous quote – variously attributed to Albie Sachs, Bill Ayers, and Leon Trotsky – to the effect: “All revolutions are impossible until they happen. Then they become inevitable.”   I still believe that a revolution in healthcare is inevitable, but have to admit that we’re still in the stage when it seems impossible.