Personalized Medicine, Unevenly Distributed

It has been almost one month since DOC happened, the curiously strong gathering curated by Jordan Shlain, MD and John Battelle. Which means I had some time to unpack the experience, the intent (“Truth in Medicine”) and the takeaways. The experience was warm and amazing, the intent admirable and more flexible than I expected.

The takeaways? Lots. But perhaps the most important meta-insight is this: to paraphrase William Gibson, the tools to achieve long term health are already here, they are just unevenly distributed. Some of these tools seem common sense:

· Healthy diet, which is out of reach for many, and little-to-no drinking.

· Exercise (even moderate).

· Quality sleep, but also the right quantity of sleep.

· Sex.

· Less stress.

· Social interactions.

· Intellectual engagement.

These are “simple” things that can slow down or even in some cases reverse chronic diseases and improve function. But even these simple things can be tough to access or implement.

But the biggest source of “unevenness” is personalized medicine, figuring out your health profile to take action, from lifestyle interventions to statins to GLP-1. In particular, there are fantastic diagnostic tools that make a huge difference, but primary care physicians rarely order them, either because they don’t know or understand their clinical utility or because they are not covered by insurance.

➡️ For example, if you want a CT angiogram because of multiple risk factors, well, it is only covered by insurance if you already had a stroke. A CT calcium score, a covered procedure, will not provide information about the severity of blockages and other data that are essential to devise a course of action. You will need to almost die to get a CT angiogram approved... or pay $300-$1,000, which is out of reach for many who would benefit from it.

➡️ But how about Lp(a)? It is not an expensive test and if you are among the 20% or so with elevated Lp(a), a genetic risk factor for cardiovascular disease, you want to know. You can adjust your lifestyle and control other risk factors. Yet this test, which only needs to be done once as Lp(a) levels are stable over your lifetime, is still unusual (but, to be fair, becoming less so).

➡️ The same goes for other types of tests, from VO2 max to serum microplastics to ovarian health to liver fat to serum proteomics and inflammation biomarkers. You need to explicitly ask your doctor for them and you probably need to know how to act on the test results. And you also probably need to pay out-of-pocket.

The lowest income groups in the US have higher rates of chronic diseases, worse functional health and around 10 years lower life expectancy. Inequalities are widening and they are coming hard for the middle class: all the diagnostic tools mentioned earlier are mostly hidden from them.

Healthy life expectancy AT BIRTH is strongly negatively correlated with how much is spent on the last years of life

Ali asked for it, here it is. The last 10 years of life are not readily available but I found the last 12 months and the last 3 years healthcare expenditures for a few industrialized countries.

1️⃣ First observation: end-of-life (EOL) health spending is proportional to the overall average health spend. The direction of the relationship is unsurprising, but I was expecting, incorrectly, a nonlinear relationship. The ratio is about 8 times the average spend for the last 12 months, and about 5 times for the last 3 years (when annualized).

2️⃣ Second observation: more interesting, the younger the average age at death, the more a country spends to keep you alive in the last few years. It's like the opposite of getting more bang for the buck: you get more pain for the buck. The same holds true for healthy life expectancy: the more a country spends on your healthcare, the shorter your healthy lifespan. Two ouliers: (1) if you are looking for the US, it is hidden behind the r score for the three bottom plots, definitely getting a lot less for your buck; (2) Taiwan, thrift spender through and through, not spend as much as other industrialized countries, not getting anything either.