Aging Therapeutics as Preventative Medicine (Why Solve Aging: Part 4)

Some of the biggest breakthroughs in medicine, in terms of number of lives saved, have been in prevention rather than treatment.

Hundreds of millions of lives were saved by vaccines (for smallpox, polio, and measles) and chlorination of water (to prevent disease transmission.)  Statins, which lower cholesterol and prevent heart attacks, have reduced coronary heart disease deaths by 28 percent.  Cervical cancer screening, mammograms, and antismoking campaigns have probably done more to reduce cancer deaths in the last 30 years than any new cancer drugs developed in that time period.

If the diseases of old age have root causes in common, and if these underlying processes of aging could be slowed or blocked, then we might see the development of a general preventative pill -- something that middle-aged people could take to reduce their risk of cancer, heart disease, diabetes, and Alzheimer’s, all at once.

Prevention in a pill is far from unprecedented. Vitamins, statins, beta blockers, and daily aspirin are already preventing chronic disease.  To the extent that the general mechanisms of aging turn out to be safely blockable, aging preventatives could join them.

“It’s called exercise.”  Yes, healthy lifestyles -- physical activity, good nutrition, adequate sleep -- are the old-fashioned ways to prevent chronic disease, and there’s something that feels virtuous about telling people to just live better instead of hoping for a medical quick fix.  

The problem is, how are you going to do that?  Promoting healthy lifestyle is a social challenge.  You might have to restructure the logistics of people’s lives, by making healthy food more available, or arranging neighborhoods to be more walkable, or making it possible for people to have more free time for cooking, sleep, and exercise. And the more systematically and radically you restructure people’s lifestyles, the more intrusive and paternalistic you’re going to be.  It’s a mess.

A medical solution, should one exist, would be a lot cheaper, easier, and more accessible; you wouldn’t have to change the very nature of cities, work, or food.  

And, yes, aging preventatives would likely be cheap.  

The current drugs that have the most evidence for aging-preventative effects, metformin and rapamycin, are $9.78 and $135 per month, respectively.  By contrast, the average new cancer drug costs $11,325 per month.  This doesn’t count the costs of cancer from hospitalization, chemotherapy, radiation treatment, or other therapies that must be done in a hospital.

Preventative medicine can sometimes be cost-saving in expectation.  According to a systematic review, low-dose aspirin to prevent heart disease, contraception, childhood immunizations and adult flu and pneumonia vaccines, STD screening, hypertension screening, birth defect and lead exposure screening, vision screening in the elderly, and tobacco and problem drinking prevention are all cost-saving interventions.  Preventative medicine that involves screening for disease isn’t always cheap, because screens take time and equipment and target a lot of non-at-risk people who don’t benefit. But cheap, quick, dramatically effective interventions like low-dose aspirin or vaccines tend to pay for themselves.

Lewis Thomas’ 1971 essay The Technology of Medicine divides medical technology into three kinds:

  • “Nontechnology” or “supportive therapy.” This is the reassurance doctors and nurses provide to healthy patients, or the comfort they provide to the incurably ill.  

    • “A great deal of money is spent on this.  It is valued highly by the professionals as well as the patients… it tides patients over through diseases that are not, by and large, understood. It is what is meant by the phrases “caring for” and “standing by.” It is indispensable. It is not, however, a technology in any real sense, since it does not involve measures directed at the underlying mechanism of disease… The cost of this nontechnology is very high, and getting higher all the time. It requires not only a great deal of time but also very high effort and skill on the part of physicians; only the very best of doctors are good at coping with this kind of defeat.”

  • “Halfway technology”, which is “designed to make up for disease or postpone death.”  Thomas says that organ transplants, emergency treatment of heart attacks, and cancer treatments including surgery, chemotherapy, and radiation therapy, are in this category.  When we don’t understand how a disease works or how to stop it at the root, we can “make up” for it by intervening on its effects. Unlike nontechnology, this actually works. But it’s very expensive.

    • “This level of technology is, by its nature, at the same time highly sophisticated and profoundly primitive.  It is the kind of thing that one must continue to do until there is a general understanding of the kind of mechanisms involved in disease...It is a characteristic of this kind of treatment that it costs an enormous amount of money and requires a continuing expansion of hospital facilities.  There is no end to the need for new, highly trained people to run the enterprise. And there is really no way out of this, at the present state of knowledge. If the installation of specialized coronary-care units can result in the extension of life for only a few patients with coronary disease (and there is no question that the technology is effective in a few cases), it seems to me an inevitable fact of life that as many of these as can be will be put together, and as much money as can be found will be spent.”

  • Finally, the “genuinely decisive technology of modern medicine”, exemplified by childhood immunizations, antibiotics, vitamins, and treating endocrine disorders with hormones.

    • “It comes as the result of a genuine understanding of disease mechanisms, and when it becomes available, it is relatively inexpensive, relatively simple, and relatively easy to deliver...Offhand, I cannot think of any important human disease where medicine possesses the capacity to prevent or cure outright where the cost of the technology is itself a major problem.”

Medical technology that really works is cheap because you don’t need to keep managing the disease -- you can “prevent or cure outright.”  

Polio vaccines are far cheaper than the older iron lungs that helped polio sufferers breathe.

Aging preventatives, should they exist, would be in this third category of “decisive medical technology”. We would understand enough about how to intervene upon the upstream mechanisms that cause the diseases of aging -- things like DNA damage, immunosenescence and chronic inflammation, stem cell depletion, and cellular senescence -- that age-related diseases would be less likely to occur in the first place.  

And, of course, you don’t have to pay for the cost of treating the diseases you don’t get.

When a very common disease is cheaply preventable, modern societies tend to make prevention free or even mandatory, like chlorinating water or vaccinating children.  An aging preventative that actually worked would likely end up in that category.  If an aging therapy stayed a bespoke treatment for the ultra-rich, that would constitute a failure -- it would signal that it was stuck in the “nontechnology” or “halfway technology” categories.