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"Target and Control" en route to "Cure and Elimination:" We Must Prepare for Good Health and Longevity

Senior Scholar, The C. Everett Koop Institute at Dartmouth, Dartmouth Medical School, Former United States Surgeon General

Correspondence: C. Everett Koop, M.D., Sc.D., C. Everett Koop Institute at Dartmouth, 7025 Strasenburgh, Hanover, NH 03755, USA. Telephone: 603-650-1450; Fax: 603-650-1452; e-mail: Koop.Institute{at}dartmouth.edu

Dr. Andrew von Eschenbach, the new director of the National Cancer Institute, spoke at the spring meetings of the National Dialogue on Cancer (NDC) as well as at the CEO Roundtable on Cancer, a pillar of support for the NDC (May 31 and June 1, 2002, respectively), and he made it very clear that whereas our old battle cry against cancer was seek and destroy, with the new designer chemotherapeutic agents, relying on genomic information, we are now in a target and control mode.

In the best of all possible futures, I would like to think that Dr. von Eschenbach could come back and address these same groups in 5 years and say we had moved on to still another phase, control and cure of cancer. If that were to come to pass, then a final sequel could be the cure and elimination of cancer.

Actually, experience with cancer and extrapolation of other scientific knowledge makes us realize that the timeline of such a progression is most difficult to predict. Imatinib mesylate (Gleevec), which was welcomed to the oncologist’s armamentarium because of its target-specificity aimed at the molecular cause of chronic myelogenous leukemia, is already encountering the expected resistance of cancer cells as therapy progresses. Christine Bahls and Mignon Fogarty, writing in the May 27, 2002 issue of The Scientist [1], present a timely summary of cancer management that will help us understand the lengthening of the aforementioned timeline.

Yet this unprecedented era of discovery in cancer management will contribute to what can only be called sea changes in public health. At best, cancer patients will shift from being categorized as victims of acute disease to those fighting a chronic disease; they will at least live longer and there will be more of them. From the broad perspectives of public health and of economics, anything that increases the chronicity of disease raises a warning flag to factor this information into health care planning.

The growth of chronic disease is a real problem for our society...but in some ways it is a good problem to have, at least better than the obvious alternative. In some ways the problem of chronic disease is a problem of riches, in this case the riches of lives prolonged by medicine. One of the reasons for the growth of chronic disease is the real success story of American medicine in treating acute disease. A generation ago, many of the Americans now facing the problems of chronic disease in the elderly would have been long since dead from a heart attack.

Now, it is true that one way to prevent chronic disease is simply to lessen our treatment of acute disease, to lessen our efforts in prevention of fatal disease. You should know, without my stating it, that I would never advocate this, but there are those who do.

When I first went to Washington, I came across a document suggesting we soft peddle advice to senior citizens on seat belt use in cars. A higher early mortality could be expected to reduce Medicare costs and social security benefits in the long run. Then there was the recent study, commissioned by Philip Morris and written by Arthur D. Little, supposedly showing that, in Czechoslovakia, the elimination of anti-smoking campaigns would be cost effective in allowing earlier smoking deaths and the avoidance of later medical bills [2].The study was, of course, flawed and the conclusions were wrong, but the mentality lingers on.

These unethical means of reducing chronic care costs lurk below the surface, especially in a society where the debate about entitlements is clouded with the persistent problem of poverty, the legacy of racism, and the demand that taxes and health insurance premiums be kept low. But the demands of chronic disease will only grow in the future as each year medicine makes another chronic disease, or really makes another acute disease chronic. For example: AIDS, only 20 years ago an acute and devastatingly fatal disease, while still fatal, has been transformed into a chronic disease from which its sufferers will die, but with which they can live for years.

In many ways chronic illness is a silent crisis, because most chronically ill Americans are neither hospitalized nor institutionalized; indeed most are cared for at home by family members. One in four Americans now provides some kind of care for a person with a chronic condition. When the baby-boomers reach 65, it is estimated that will be three in four. But the increasing unavailability of family members to provide this assistance means that the unmet needs of the chronically ill will skyrocket. These unmet needs, such as help in bathing, or getting out of a chair, or cooking, or eating, or walking, or shopping lead directly to the injuries or illnesses that force hospitalization or institutionalization, with all its attendant costs and stress.

To deal with these folks, American medicine and American society need not only improved skills and therapies, but also an improved attitude to enable our quick-fix culture to deal compassionately and effectively with the long-term problems of the chronically ill and their families. The problems of chronic care and of long-term care need to be addressed now, not only by the health-care system, or by the afflicted families, but by the entire American society. We are not socioeconomically prepared for the increase in chronic disease or the burden on caregivers without considering cancer patients. With them, the burden will be great and the cost, at the moment, almost incalculable.

If these predictions come to pass, the good news is that in the long term this will be a transitional period, although one that will tax seriously the public health community before the long-term goals of control and cure and cure and elimination can be realized.

C. Everett Koop, M.D., Sc.D.

REFERENCES

1. Bahls C, Fogarty M. Reining in a killer disease. The Scientist 2002;16:16.
2. Fairclough G. Philip Morris Says Smokers Early Deaths are Good For Economy. The Wall Street Journal 2001;07/16/01

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