Medicine hasn't stalled: it cured hepatitis C, but not old age

Thirty years of medicine: hepatitis C is cured, aging is not

A man in his early sixties. Months later, a lifelong family friend, the kind who drops by the house. In both cases, the same phrase: we're sorry, there's nothing we can do. Anyone who goes through it draws an uncomfortable conclusion: we're still dying at similar ages, from diseases that already existed. The question isn't whether medicine works, but whether the model that funds it has stopped delivering.

Life expectancy has flatlined, and it's not for lack of effort

In the developed world, life expectancy has barely moved in years. The body has a ceiling, and what was left to gain is no longer in the operating room: current estimates attribute more than 90% of the historical rise in life expectancy to hygiene, and considerably less to medicine. The rest came from an unrepeatable window — antibiotics, surgery, tobacco, obstetrics — summed up in a household analogy: going from the Beetle to the Golf IV was a leap; from the Golf IV to the Golf VIII it's just a facelift and a touchscreen.

One memory is enough to measure it. The pediatrician who stubbed out his cigarette in an ashtray filled to the brim before picking up his stethoscope, his office looking like a dockside bar. That was medicine in 1990. Nobody smokes in a doctor's office anymore, and that change, not a pill, is what has done the most for public health in three decades.

What has been cured while nobody was watching

Thirty years ago, cystic fibrosis came with a life expectancy of about 25 years; today it's around 65 because mortality has plummeted. Spinal muscular atrophy used to kill its sufferers as babies, and today virtually no one dies of it. The same has peine with some forms of epidermolysis bullosa. Hepatitis C is curable, HIV is a chronic disease where it once killed within a few years, and direct-acting anticoagulants — dabigatran, apixaban, edoxaban, rivaroxaban — have transformed the management of atrial fibrillation. Immunotherapy has extended survival in several cancers and autoimmune conditions.

Why doesn't it show? Because those patients are few, and because someone who dies at 82 from metastasis is still dying at 82 from metastasis. Pogre has become surgical: a specific disease, a specific patient, a modest result. Gaining another twenty years of life expectancy across the board is on no one's roadmap.

Rolling the dice costs a fortune: 92% come to nothing

Only 8% of compounds that show any active principle ever reach the market; the other 92% fall by the wayside after burning through the budget. Phase 3 and 4 trials require tens or hundreds of thousands of patients, and a late result can sink a treatment that once looked promising. On top of that, patents expire: the moment they do, anyone can make the generic, and some countries — India, Pakistan, Argentina — fast-track their way around patents.

Against that backdrop, the accusation that the industry prefers managing disease to curing it runs into an uncomfortable fact: 90% of medicines are developed by private pharmaceutical companies, nearly all American, while public research plays a supporting role — lending out the ultra-expensive chromatograph no company would buy for a one-off test — and gets paid in cash, not royalties. With only four big players, the competition that drives pogre arrives more slowly. It isn't sabotage; it's concentration.

The gap no clinical trial can fill

One limit is easier to see in the doctor's office than in the lab. People who live alone die sooner, and not for lack of drugs: they get tangled up with their pills, stop going to the pharmacy, don't book appointments. There are tumors caught early because a son or daughter insisted, and tumors caught after paying for a private consultation, because past a certain age preventive mammograms are no longer offered. Family acts as triage where the system falls short, and there is less and less family.

There lies the unsettling figure: healthcare has improved so much that it's only noticeable when it's missing.