Much of the progress in medicine during the past half-century has involved expensive, high-tech diagnostic tests and therapies. The trend in this direction worries health economists and politicians because it has the potential to send already-high health care costs into the stratosphere.
In both medicine and dentistry, however, there is an important role as well for ingenious, low-tech, less expensive approaches to improved health and increased longevity.
High-Tech Solutions Make Health Costs Skyrocket
In May, the Food and Drug Administration approved a gene therapy drug, Zolgensma, for a rare childhood genetic disease, spinal muscular atrophy, that costs just over $2 million for the single dose of treatment. The illness, which is caused by a defect in a gene called SMN1, affects about 400 babies in the United States annually and kills those with the most common form of the disease in the first few years of life. The new treatment uses non-pathogenic genetically engineered viruses to deliver healthy copies of the SMN1 gene to patients' cells so they can synthesize a protein needed to develop normal muscle neurons.
Nusinersen, approved in 2016, is another high-tech, hugely expensive drug used to treat the same disease. It acts via a different mechanism; it is an antisense oligonucleotide that alters the processing of a gene, SMN2, which is similar to the deficient one, spurring the production of the needed SMN1 product. Nusinersen costs $750,000 in the first year and $375,000 annually thereafter, making it probably the most expensive drug in history.
Interestingly, high-cost, high-tech innovation doesn't always offer improvements. A multi-year study of almost 24,000 patients with kidney cancer by researchers at the Stanford University School of Medicine found that robot-assisted laparoscopic surgeries are associated with increases in operating times and costs compared with traditional (non-robot-assisted) laparoscopic surgeries. The clinical outcomes revealed no statistical differences for patients, including no differences in length of hospital stay.
Small Interventions Can Make a Huge Difference
Although the miracles of high-tech may capture the imagination, there are many simpler and cheaper yet tremendously important innovations for diagnosing and preventing illness. For example, a 2017 article in the American Journal of Medicine described how a single blood test can ascertain that a patient in the emergency room is not having a heart attack and so can forego the inconvenience and expense of additional invasive tests or unnecessary hospitalization.
The highly sensitive blood test measures levels of cardiac troponin, a protein involved in muscle contraction. If the level were undetectable — that is, below the limit of detection of the test — there was greater than 99 percent likelihood the patient was not experiencing a heart attack and was at very low risk of other cardiac adverse events for at least 30 days. That innovative approach is advantageous to patients and helps to reduce the frequency of hospitalizations and, therefore, health care costs.
Sometimes, a simple tool or device is important to clinical diagnosis. One example is the handheld direct ophthalmoscope, which allows a medical practitioner to look into the back of the eye to ascertain the health of the retina, optic nerve, vasculature, and vitreous humor. Invented in 1851, it costs less than $200.
Consider falls, which are both a cause and effect of declining health in the elderly. They are the leading cause of injury-related visits to emergency rooms and the primary cause of accidental deaths in Americans over the age of 65.
To measure the potential benefits of a low-tech approach to preventing fall-related injuries, a research group in New Zealand compared rates of falling and injuries from falls on low-impact flooring, (which is made of slightly spongy material like that on many playgrounds) with falls on standard vinyl flooring in an "older persons health ward." Falls were prospectively monitored with written reports of all incidents, noting the location and consequences of each fall.
Over the 31 months of the study, 278 falls occurred among 178 people who fell. The rate of falls was indistinguishable in the two groups, but "fall-related injuries were significantly less frequent when they occurred on LIFs (22% of falls versus 34% of falls on control flooring)." And many of those averted injuries were serious: "Fractures occurred in 0.7% of falls in the LIF cohort versus 2.3% in the control cohort," more than a three-fold difference.
Thus, the New Zealand study provides a compelling rationale for adding low-impact flooring to housing for seniors, along with other modifications.
Consider These Low-Tech Solutions
Other low-tech innovations can save innumerable lives, especially in parts of the world that cannot afford expensive health interventions:
- Water filters. Hundreds of millions of people around the world lack access to safe water. Simple, cheap water filters that use ash (a byproduct of thermal power plants) combined with silver nanoparticles to filter out impurities and pathogens have improved the lives of hundreds of thousands of people.
- Vaccine-delivery devices. Vaccines are possibly the most effective and cost-effective public health intervention in history, but in the developing world or in other places with poor health care infrastructure, the means to administer them can be problematic. One solution is a jet injector that can send a high-pressure, directed stream of fluid through the skin.
- Oral rehydration solutions. Oral rehydration salt solutions to treat the symptoms of diarrheal diseases were a huge advance. Simply a mixture of salts, sugar, and water (sometimes with zinc added), this simple innovation is perhaps the most cost-effective existing treatment of a life-threatening disease. These solutions could be made even more effective with the addition of proteins such as lactoferrin and lysozyme.
- Microscopes. Sophisticated laboratory microscopes are useful for diagnosing infectious diseases, but they're heavy and expensive. Paper microscopes, also known as foldscopes, contain all the crucial parts and unfold like a work of origami. They cost less than a dollar to manufacture, and they suffice.
- Checklists. Safety checklists in operating rooms and intensive care units are essential as they "appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity."
- Fluoridation. Dentistry has also benefited from costly, high-tech innovations such as dental implants, but improvements in low-tech options can also provide much-needed benefits for dental health.
With Fluoride, a Million-Dollar Smile Comes Cheap
Tooth decay remains one of the major public health concerns for both developing and developed countries, according to the World Health Organization. It is considered one of the most common chronic problems in the United States, where most adults will have at least one cavity in their lifetime.
Decay causes inflammation in surrounding gum tissue, abscesses, and eventually tooth loss. In addition to taking a significant toll on quality of life, decay and periodontitis has been linked to an increased risk of cardiovascular events, systemic infections such as endocarditis, and complications in pregnancy.
Medicine has made significant advances in replacing and restoring teeth that have needed treatment due to dental cavities, and these procedures are often costly. Preventing the problem in the first place is optimal, however, and an important advance was discovered in the middle of the last century: Water fluoridation, a simple, low-tech intervention with proven efficacy, was introduced to the first U.S. city in 1945.
The concept is that fluoride, a negatively charged ion, binds to calcium and phosphate on tooth surfaces to prevent the bacteria that cause cavities from even entering the tooth, thus protecting the teeth from dental decay and in some cases even reversing early decay. In a 2014 systematic review, researchers found that fluoridating drinking water in communities decreased overall decay and, thereby, the costs of more aggressive and costly dental interventions.
Currently, the Centers for Disease Control estimates approximately 100 million Americans are still without access to fluoridated water. Introducing this low-tech, high-impact measure more widely would substantially decrease the need for many dental procedures. (We should add one caveat about fluoride intake in pregnant women, however: A prospective birth cohort study published only last month in JAMA Pediatrics found that "fluoride exposure during pregnancy was associated with lower IQ scores in children aged 3 to 4 years ... indicating the possible need to reduce fluoride intake during pregnancy.")
High-tech miracles will continue to attract the headlines, but to control health care costs, we also need simpler, inexpensive innovations. In the words of Marine Corps Commandant Gen. David Berger, "We must continue to seek the affordable and plentiful at the expense of the exquisite and few." Let's put research dollars into finding them.
Henry I. Miller, a physician and molecular biologist, is a Senior Fellow in Healthcare at the Pacific Research Institute. He was the founding director of the Office of Biotechnology at the FDA. Please follow him on Twitter at @henryimiller. Dr. Sharma, a California dentist, owns Palo Alto Oral Health.