Stem Cells – Myth and Reality

NPR ran an interview (Stem Cells the Untold Stories) with Dr Doris Taylor a pioneer in the science of regeneration who is known for bringing dead heart tissue back to life. The discussion was revealing on so many fronts and is worth highlighting some of the details especially as they relate to Stem cells. As she points out if

we had found different vocabulary to discuss stems cells in public at the outset, distinguishing between fetal and embryonic cells, explaining the origins of the cells used in research, and illuminating the larger story of stem cells.

There is a significant difference between these two forms and they get confused in the media and in general discussion.

stem cells are really very simple. They’re cells that can do two things: They can make more of themselves or self-renew, and they can, quote “differentiate,” become a lot of different things, differentiate. And, really, we have stem cells everywhere in our body. …. I believe aging is a failure of stem cells. That every organ or tissue in our body for the most part has stem cells in it…..The word that’s used is embryonic stem cell, and the concept is that we’re taking fetuses and using those to create cells for medicine. That is just not true. Fetal cells are already muscle, already heart, already lung. They’re not stem cells anymore

In fact Stem cells are involved in healing and repair all the time – every time you scratch or damage you skin stem cells help int he repair. As we get older that repair process declines in effectiveness and how good the repair looks to the original. Think about the baby who gets a cut vs the elderly mother. The baby might show no scar, the mother a much clearer scar indicating the location, size and severity of the damage.

Stem cells are involved in so many aspects of our bodies. Linked to aging and the clock on every cell – the little piece of DNA at the end of every chromosome called a telomere. Every time your cell divides this gets shorter eventually reaching a point (cell death?) that is too short and no more division is possible. Unfortunately stress shortens these telomeres and hence actually ages your stem cells. If you believe that’s true (and the evidence is compelling and I do) that means it ought to be possible to reverse stress and make your cells younger. In a study of one (Matthieu Ricard a famous French philosopher Buddhist who’s worked with the Dalai Lama who wrote a book called Happiness) reviewed stem cells in the blood before and after meditation – they found a huge increase in the number of positive stem cells in blood.

Largest increase I’ve ever seen after 15 minutes of meditation.

Start meditation now – in fact I can recommend this book – The Monk Who Sold His Ferrari for all you business types! And other types of damage or disease can be seen as a failure of stem cells – cancer for instance

Cancer is basically cells gone bad. It’s cells that no longer know when to stop dividing. What’s a stem cell? A stem cell’s a cell that can self-renew, make a lot of itself and keep dividing, and become a lot of different things. What’s a tumor cell? It’s a cell that can make a lot of different cells and become a lot of different things. In some ways they’re very similar, but a stem cell has the signals that know when to stop dividing. Tumor cells don’t.

Cancer could be some dysfunction of stem cells as the body tries to combat aging and the failure of the stem cell repair mechanisms.

Some highlights in Stem Cell research suggests

• that decreasing stress increase the number of stem cells that you have in your body and in your blood
• Meditation increases the number of positive stem cells
• men and women have different numbers and different kinds of stem cells – perhaps part of the reason why men develop heart disease earlier than women as they lose stem cells faster
• Cancer is some kind of dysfunction of stem cells
• Aging is reversible and stem cells are part of the answer

As Dr Taylor puts it

Drive carefully. We have two cemeteries and no hospital. And that’s really how we have to approach this field. Drive carefully. And yet we’ve got to keep driving because it matters. It matters. And we can already do things that 10 years ago we thought were absolutely undoable

Don’t wait for something to touch your life to understand the opportunity before us

people usually don’t care about things until it touches their lives. And once it touches their lives their perception changes. And I can’t tell you the number of people who don’t believe in research or don’t believe in science or don’t believe in innovative approaches to medicine until it’s their daughter or son or brother. And then all of a sudden, they’re at least open to the conversation

Go spend some time in the pediatric intensive care facility, with the disabled child struggling to sit up, the Veteran who lost a limb, the incapacitated grandparent who cannot watch her grandchild play because she needs oxygen therapy constantly, or the parent who wants to see their child reach double digits.

I’ll publish any intelligent commentary, debate or opinions. In fact I welcome intelligent discussion and debate. Can you see it or is such a polarizing issue that we will medicine continue to languish with restricted access to essential tools and techniques derived from Stem Cells?

Incentivise Healthy Behavior

Stephen Colbert “the Word” segment – this time on “Share the Wealth”. He sees a silver lining to the Obama Policy on Healthcare – Here’s the link

Joking aside there is an interesting thought in this piece – providing care should come with some demands on personal behavior. Self destructive unhealthy behavior has significant consequences and finding some way to incentivise healthier behavior as part of providing complete coverage has some merits.

Is that really possible – it is fraught with problems and issues but Adam Bosworth floated a similar concept some weeks ago at TEPR (The Changing World of Healthcare) providing cash incentive’s to the population to encourage weight loss. Radical thinking, but in terms of value for money he made a compelling argument that this would pay of handsomely in the future given the high cost of treating diseases later in life.

Healthcare Standardization and Rationing

The knee jerk reaction’s are out – this one from Bloomberg that suggests the Stimulus package and Obama will “Ruin your Health”, and this an “alert” on a blog suggesting this is “nationalizing” healthcare. There is a mad dash to kill the stimulus bill and in particular the health care elements that could limit access to health care by developing standards, defining protocols and determining if care is cost effective.

These are all hard discussions and hard decisions and I talked about this before in my posting on “Who Should pay for healthcare” that detailed some of the challenges faced in other countries in particular the UK which has developed the National Institute for Health and Clinical Excellence (NICE) group to attempt tackle these problems in a more scientific and rigorous fashion. This kind of reaction typifies the channel that everyone is listening to WIFM (What’s in it for me). Of course no suggestion of what we can do to deal with the rising cost of healthcare – the most expensive delivered in the world but only No 23 in quality of life measures. The scaremongering on this issue is based on scant data – if you want a sobering read I suggest you look at this report from the Insure the Uninsured Project web site titled: “Health Care Systesm Around the World” (warning pdf). While they all suffer some of the same challenges they are attempting to address them and in most cases doing a better job at delivering care.

I have to ask…..Betsy McCaughey says:

Keeping doctors informed of the newest medical findings is important, but enforcing uniformity goes too far

Why exactly? Do you want each physician trying his own brand of medicine, sampling different techniques, reading about some new innovation or drug and using that. You only have to look at the lack of science behind the Alternative Medicine billion dollar industry in Trick or Treatment to get a sense of how easy it is to be deceived into believing something offers value when it does not. Then look at the low compliance with known treatment protocols to understand that the system and its care givers are creaking under the strain of overwhelming data and choices. This from the AHRQ site on quality measures:

In one study, the overall rate of prescribing beta-blockers to patients after suffering an acute myocardial infarction (AMI) was 50%, and the rates of prescribing for family physicians was lower than those of specialists.

Yet we know this saves lives. But perhaps it is Betsy’s view that we are wrong to see healthcare as a “cost problem instead of a growth industry” and suggesting Healthcare “produces almost 17% of the nations’s GDP”……this is just astounding. I am certain that our car industry does not want to see healthcare as growth industry. They cited healthcare costs as a major contributor to their difficulty in competing.

If we made every last cent of our available resources available to pay for healthcare we would still not have enough. The industry and our technology will continue to create treatments, drugs, therapies to consume those resources (and typically those treatments are of higher in cost especially when first launched).

None of this is easy – but the resources are limited and as such there must be some mechanism to share the care and get the best we can for as many that we can. We don’t currently on all the generally accepted healthcare quality metrics and we pay by far the most per head of population. The system is broken. Left to our own devices we all clutch at any possibility no matter how remote or how unlikely the improvement in outcome might be (and in some cases actually harmful).

Perhaps the alternative is to leave it to the individual – put the patients in a room and ask them to justify the treatment amongst themselves and share the limited available dollars on the care. When they agree the care can be delivered. Of course that won’t work – no one wants to face those difficult choices or decisions and overlaying the additional emotional burden on this decision is not going to help. So others will have to make some of these choices and providing sufficient data to make informed decisions is essential and trying to apply some level of analysis and data to try and make it as “fair” as possible.

Agree…..disagree let me know. This is nto an easy issue but it does need to be addressed as satus quo is failing…rapidly.

Who Should Pay for Healthcare

A recent twitter on my part to an article by Health Imaging titled: “Americans want healthcare reform, but divided on how to pay for it” raised some comments that are worth exploring. The simplistic 4 word response I got back from one individual:

The Government should pay

Simply passes the responsibility from individuals to a group who receive power, authority and most importantly money from the same individuals . They are then charged with the responsibility of sharing out the limited resources “fairly”. As history has vividly demonstrated the challenge with fairness and charging a smaller group with equal distribution and fairness is problematic. George Orwell’s allegorical novel Animal Farm detailed some of these challenges.

Healthcare remains a central challenge to countries worldwide. Those with more resources do spend more of them on healthcare for their population. But there is no bottomless pit of money to pay for healthcare and unfortunately as the population gains increasing access to better healthcare their reaction is not satiation to the higher levels and increased life expectancy but wanting more. Countries approach this challenge in different ways – the UK healthcare system rationed healthcare with waiting lists and limited availability. In recent years they have attempted to define the rationing standards for healthcare under the banner of the “National Institute for Health and Clinical Excellence (NICE)“. A recent ruling on drug therapy

… it ruled that four drugs for advanced kidney cancer were too expensive for NHS use. The four treatments, NICE acknowledged, ‘have the potential to extend  progression-free survival by five to six months, but at a cost of £20,000 to £35,000 per patient per year’.

Their methodology assesses value against “Quality Life Adjusted Years” (QALY’s) that attempt a cost benefit analysis on treatments relative to potential outcome and quality of life. This is a difficult calculation even in the best of circumstances because the assessment of benefit changes dramatically from the perspective of the individual who in most cases assesses the value even if limited in time or effect.  In the case of the drugs for kidney cancer drugs NICE’s QALY assessment was”

Translated into QALYs—quality adjusted life years—that works out at between £71 000 and £171 000 a year; well above the rough threshold of £30 000 a year that NICE broadly applies other than in exceptional circumstances.

I commented on the NICE measure before where an individual wanted to pay for the drugs himself but in doing so fell out of the group coverage and was refused access.

There is no such thing as “free healthcare” – free at the point of service removes personal responsibility and encourages abuse. A simple case in point is the nuisance charge or co-payment. The United Kingdom has provided free home visits and free access to their General Practitioner for years.  But you only have to spend a night with an on call General Practitioner, especially round any holiday to experience the abuse. Calls at 3am for a headache. And not a new onset headache but one the patient has been suffering from in some cases days, weeks and even months. The introduction of a payment for all visits would discourage some of this and those opposed would suggest that it might discourage patients that should make the call. It might but the underlying issue of value would be solved – if the service is “free” then the value is perceived to be the same.

Providing healthcare to as many people as possible is right but in all cases a line must be drawn that is entirely dependent on the resources available. One can imagine that the availability of healthcare is much diminished in Zimbabwe. There the provision of midwifery delivery services to a preganant mother would require the patient to personally provide $20 Billion  Zimbabwean dollars (nearly US $40). But the resources available make this a bridge to far. And so to in all other countries – where we continue to consume every available healthcare resource made available. There is no instance where a country so much makes healthcare available that there is resources left unused, clinics and doctors desperate for patients because they are underutilized.

So what is the answer – personal responsibility and a full understanding of the cost and benefit of healthcare resources available. Attaching value to those resources helps comprehension. Patients can make informed choices in the same way that consumers do – why pay more for the iPod when a Micosoft Zune or SanDisk Sansa does the same job at a lower cost. Some do make the choice for iPod, others do not but they do so based on the available data and a cost benefit analysis. But if all the MP3 player’s were free or the same “cost” to us then the selection is harder and less informed. Free healthcare is a misnomer – everything has a value and attaching a value to healthcare but making it accessible to as many as possible is better strategy than just making it free.

Featured in the March issue of the British Journal of Healthcare Management – Stimulus and Effect: Rationing (full pdf subscription required)

End of Life Directives – Engage with Grace

Important concept that everyone should pay attention to. This is a difficult conversation but a very important one given the increasing capabilities of medicine

Engage with Grace is a Viral Social Networking Initiative to get everyone to start discussing their desires at the end of our lives

Visit the site here

Simple important stuff – not all cures are worth it to all people and letting everyone in your life know what you want and providing them with the necessary tools (typically power of attorney and or advanced directive) to help them fulfill your wishes if you become incapacitated