Drugs are doomed

There’s no question that pharmaceuticals – and the industry that produces them – have saved untold numbers of lives and reduced suffering on a scale that is unprecedented in human history. But I believe we are entering a new phase in which the viability of pharma is based more on faith than on evidence. The key question for the survival of pharma is whether and for how long we retain faith in its power to better our lives.

Medicine has always been with us, but medicine means different things in different eras. The expectation that drugs and concoctions would actually cure disease – which seems blindingly obvious now – is relatively modern. Despite thousands of years of trial-and-error, and what we in our post-Malthusian era regard as desperate clinical need, there were no more than a handful of safe and effective drugs available before the 1880s. Medicines and medical practitioners were expected only to comfort patients and alleviate their suffering. And they were actually pretty good at that. Questions of life and death were the prerogative of gods, not medicine.

That attitude changed after Germ Theory made possible the first scientific medicines – medicines that both prevented and cured infectious diseases, the leading cause of death in all countries. Germ theory also gave a theoretical foundation to the practice of antisepsis, which along with the development of anesthesia, enabled the development of surgery beyond rapid amputations and other crude operations.

We now think of medicine as mostly consisting of surgery and drugs. Consequently, surgeons are among the best-compensated doctors, and pharmaceuticals are the most reliably profitable industry.

But pharma is facing a squeeze. The cost of developing a new drug has risen, inexorably and exponentially, for decades:

From Eroom’s Law

I’ve argued that this rise is due to biology – that there are a finite number of drug targets, and that we have already found most of them, certainly most of the “easy” ones.

Although the cost of developing a new drug may rise unchecked, our ability to pay cannot. And it may be time to re-evaluate our willingness to pay as much as we do. Drug expenditures rise year after year, but our benefit from these expenditures does not. If we are indeed running out of good drug targets, then we expect to see less benefit, on average, from new drugs than we did from old ones. Let’s take a look.

Here are per capita drug expenditures in the US:

Data from Spending on prescription drugs has risen rapidly over past decades

And here is the change in US life expectancy over the same time period:

Data from FastStats

This is life expectancy from birth, which is heavily influenced by infant mortality. Since infant mortality had already hit very low levels in the US by this time period, it is perhaps more relevant to look at life expectancy at age 65 – which is where we might really expect to see the benefits of new and more-effective drugs:

Data from FastStats

In both cases we see steady progress, although perhaps a leveling-off in recent years. Now let’s plot life expectancy vs drug expenditures:

The first $200 of drug expenditures buys us several years of increased life expectancy, but the years of life bought per additional dollar spent on drugs slows considerably above that.

At a more-granular level, we are witnessing the rise of new cancer drugs which routinely cost over $150,000 per treatment, yet show little or no improvement in survival as compared to relatively inexpensive chemotherapies.

These trends are not sustainable. At some point, what seems the natural order of things – that drugs are equivalent to medicine, and that we can never have enough new drugs – could start seeming much less obvious. Our willingness to pay $120K for marginally useful cancer drugs could collapse with remarkable speed, and we will all wonder why we ever thought that they were a good idea in the first place. That’s the weakness of any faith-based system – it only takes a few unbelievers to undermine the whole edifice of delusion and bring it crashing down.

Cheaper, older, highly-effective drugs – vaccines, antibiotics, diuretics, chemotherapeutics, etc – are not going to go away. We will still have them and use them and live into our 80s. We will continue to develop new drugs, but will be less willing to be bamboozled into paying premium prices for pedestrian results. And we will begin to acknowledge that public health interventions are far more effective than therapeutics in improving health. Drugs (and surgery) are not only expensive but invariably have adverse effects. Preventing disease is far less expensive and much more effective than treating disease.

In other words, the drug industry as presently constituted is doomed. We will realize that it needs us far more than we need it. I give it a decade before it begins to implode.