The Future of Healthcare
The following is the last chapter of my Book: Ketones, the Fourth Fuel. The book was inspired by the life’s work of Otto Warburg, Hans Krebs, George Cahill and Richard Veech; work that culminated in the discovery of Ketone metabolism. Their message within seems especially important as we live through this viral pandemic.
How will future generations perceive our current health care system, what we, today, call “modern medicine?” Will they shake their heads in disbelief? Will the flaws seem obvious to them, that today are clouded, murky and unclear to us? Will future generations feel a twinge of empathy for us? Modern medicine, to be sure, has miraculous capabilities that our ancestors would marvel at: Imaging technologies like CT scans and MRIs, robotic-guided surgeries, and artificial intelligence programs that can diagnosis cancer far better than humans can. Yet, even with these advanced technologies that transcend human capabilities, something feels…off. We can build AI programs that predict the exact molecular architecture needed to design a new drug that docks to a specific receptor, yet 40% of the population is obese — and over half are pre-diabetic or diabetic. We can visualize our inner selves with CT scans, ultrasound and MRIs yet depression and anxiety run rampant. Perhaps we’ve veered off course. Perhaps we have focused on the trees at the expense of the forest — we have favored technology over simplicity and we have lost sight of something critical — the real meaning of health care.
Warburg, Krebs, and Veech, each of a different generation, felt the same thing. All three of them entered the world of clinical medicine as medical doctors and paused. All three felt a visceral pull drawing them to look beyond the known science to something more essential yet elusive. Something fundamental. This shared pull may have been communicated at an unspoken, unconscious level. Yet the desire was translated into something real: The continuum of research; from Warburg to Krebs to Veech; ultimately defined the manifest qualities of ketone metabolism.
Still, the stunning therapeutic potential of ketosis falls into a health care system that has shown little interest in free or dirt-cheap therapies. There is simply no financial incentive for Big-Pharma or physicians to care about low-cost therapies. Unglamorous therapies like fasting, ketogenic diets, or non-patentable ketone supplements attract little money and therefore little attention. The mismatch between the potential value of these therapies and their adoption by the health care system is staggering — it’s like valuing Amazon or Apple stock at close to zero. We spend billions annually on chemotherapy drugs that change outcomes by mere weeks or months; billions on stents, statins, bariatric surgeries and diabetes drugs and devices that don’t even scratch the surface of the core problems of insulin resistance, diabetes and obesity. Big Pharma has spent billions on developing drugs for dementia, Alzheimer’s and Parkinson’s and have come away empty handed. Yet, we have this incredibly promising, perfectly safe, and incredibly cheap therapy sitting right in front of us that is largely ignored. This frustrated Veech. “He was optimistic that each publication would convince people of the ester’s importance, but then he often felt let down,” said one of Veech’s closest friends. He truly thought the ester could change the world, changing the lives of billions of fellow humans for the better. He felt the ester was the “equivalent of the discovery of penicillin. If not bigger.” Clarke, the co-developer of the ester, still believes that the ketone ester will eventually be “more or less a general tonic for the general population.”
Future generations will most likely be befuddled by our current approach to health care. Strangely, we place each disease into its own little-box and wait until it’s entrenched within us, when it’s too late, before we attempt to treat it. Physicians surgically rearrange vasculature or insert stents to treat failing arteries. They make futile attempts to salvage a body riddled with cancer by dripping in toxic chemotherapy drugs or burning with radiation. They prescribe insulin shots for people with diabetes, steroids to quell autoimmunity, and so on. But a sober top-down analysis reveals how misguided this purely reactive strategy is. Consider this: if a pill was invented that cured cancer tomorrow it would only extend the human lifespan by 2.9 years. Why?: The unremitting process of entropy will foist some other age-related disease immediately upon us. The same holds true for all other major diseases. According to an analysis preformed from scientists at University of Southern California, University of Illinois at Chicago, Harvard, Columbia, and other institutions, “Lowering the incidence of cancer by 25 percent in the next few decades — in line with the most favorable historical trends — would barely improve population health over not doing anything at all. The same is true of heart disease, the leading cause of death worldwide. About the same number of older adults would be alive but disabled in 2060 whether researchers do nothing or continue to combat cancer and heart disease individually.” Yet, investing in therapies that combat aging stand to pay enormous dividends. According to the analysis, “Even modest success in slowing aging would increase number of non-disabled older adults by five percent every year from 2030 to 2060.” Proof of this is easy to come by: extending the lifespan of mice by caloric restriction postpones all age-related diseases. To parse disease up and battle each condition individually is trying to reverse entropy at its zenith — it’s a losing game. The efforts of health care should focus on prevention over cure; pharmaceutical research should be redirected toward anti-aging interventions.
Of course, the power of prevention is nothing new but it remains universally true. The well-known adage once quipped by Benjamin Franklin: “An ounce of prevention is worth a pound of cure,” is as true today as it was when he first said it in 1736. The idea that a little prevention has much more value than a lot of cure not only makes intuitive sense, it is in harmony with the physical laws of the universe. The second law of thermodynamics states that the universe spontaneously trends toward an increasing amount of disorder, a process known as entropy. A health body has low entropy — it is highly ordered. A body with cardiovascular disease, cancer, or metabolic syndrome, for example, has high entropy, it is rapidly treading toward disorder. Instead of trying to fix the damage while the waters are rising, we should be damming the river. And we know the source of the river. In the world of biology entropy goes by a different term: aging. All of the Western world’s leading killers are ultimately caused by the aging process. To address aging is to address virtually every disease process. It’s difficult to undo entropy. It is far better to try to preserve order as long as possible. And this, Veech claimed, is precisely what ketone metabolism does — preserve the highly structured order of our bodies, keeping it thrumming along optimally — a sophisticated, internally-installed therapy that evolved over eons to keep us healthy and reproducing, fulfilling our Darwinian imperative.
It’s worth pointing out that the vast majority of the twentieth and twenty-first century breakthroughs in biology do not come from man inventing something de-novo, they arise from man borrowing nature’s intellectual property: genetic engineering, monoclonal antibodies, CRISPR, stem cell induction and cloning; all of these inventions, most of them blessed by a Nobel Prize, are less inventions in the true sense, and more just manipulations of the exquisite biological systems that nature honed over millions of years of evolution. Why re-invent the wheel? And truth be told, we are not yet very good at it. Man-made drugs are typically blunt, clumsy, and indiscriminate. Our attempts to target a specific disease process with drugs almost always come packaged with a litany of unintended side-effects. This is not to say we won’t be better at de-novo drug development in the future — we are just not that good at it yet. Our attempts to slow entropy in one location speeds it up in others. The totality of healthcare seems more like a game of whack-a-mole against entropy: drugs that attempt to undo arterial plaques and untangle neurofibrillary tangles. Surgeries that attempt to “cut out” or “bypass” entropy wherever and whenever it surfaces. Our healthcare system needs to be turned inside-out.
Heading these lessons from physics, the primary goal of health care should be to preserve our momentary gift of order — prevent entropy as long as possible. To this end, Veech’s final message was that we don’t need to look too far. We don’t need to try to invent something new. We own natures IP. Our bodies have a targeted, preventive-strategy already installed that can be triggered by fasting, a ketogenic diet or by ingesting the ketone ester.
Richard Veech died on February 2, 2020, shortly after addressing an audience of his peers at a conference in New Mexico, or as he might say, his “great” controlling nucleotides reached their final equilibrium. Genius often appears in unusual packages. Those that knew Dr. Veech well universally describe him as a colorful character. To be clear, he had little patience for fools. He was refreshingly, and at times, shockingly, blunt. He called it exactly how he saw it, using as few words as possible and with little concern for political correctness. “Read the damn papers,” he once told a reporter asking him to explain the ketone ester’s significance. Although some were obviously put-off by his rough edges, others appreciated his straight-forward style. Those I interviewed for this book who were close to him, unquestionably loved him. Veech had no interest in fame or self-promotion: in fact, he felt that it was “unseemly for doctors to promote themselves,” insisting instead to be judged on the merit of his work alone.
There was another side to Dr. Veech. For those he loved he was gracious and thoughtful, as illustrated in a letter he wrote to the two sons of George Cahill upon Cahill’s death: “It is one of my proudest accomplishments to have been cited as a single co-author with Dr Cahill [on] one of his last publications. Dr. Cahill died at 85 while singing with two of his daughter’s Handel’s Hallelujah Chorus. I related this to a young student studying ketosis in athletes and she exclaimed ‘He must have gone immediately to heaven.’ That is an idea that all of us who knew him would share.”
The legacy of a scientist is a curious thing. All too often it is not fully appreciated until after they are gone. Many of the scientists in this book: Warburg, Krebs, and Mitchell were fortunate enough to have received recognition in the form of a Nobel Prize while still alive. Although Veech was never awarded a Nobel Prize, in the final analysis time may prove his research — his message — to be just as far-reaching. Perhaps even more profound than his predecessors. It is poetic, in a way, that the human side of this story synchs with Veech’s professional legacy. Warburg took a chance on Krebs — an inexperienced medical doctor at the time — as did Krebs with Veech. Together, in the end, their combined research wove a tapestry that transcended each of their individual careers and accomplishments. Although awards are given to individual scientists, advancements in science are never an individual achievement. It is a collective effort — a canvas that is filled-in over many generations. Science is the most altruistic and unselfish of human activities — an offering — the gift of free and accumulating knowledge. “If I have seen further it is by standing on the shoulders of giants,” said Isaac Newton. And like the transgenerational canvas of science, the first part of Veech’s professional legacy revealed our metabolism to be the same: reactions evolving into pathways, evolving over eons into a single, interconnected whole. A lattice of thousands of harmonically connected reactions controlled by the four “great” nucleotide coenzymes. The second pillar of Veech’s legacy was revealing the potent therapeutic qualities of the misunderstood and often maligned fuel molecule, beta-hydroxybutyrate. Operating through the four-nucleotide coenzymes, it alone could change the complexion of our entire metabolism in ways that were once thought immutable. The legacy of Veech will continue. The fascinating qualities of BHB are still being uncovered.
What does the future hold? What will health care look like in the generations to come? It might feel excruciatingly slow at times but the vector of human progress is always forward. As physics has taught us, this forward march of societal evolution is baked into the fabric of the universe. It is an extension of the order-seeking eruption of life itself. Gravity is the universal fountain-head of order. The flow of negative entropy from our sun that spurred the formation of life doesn’t stop there. Nature repeats patterns. Bear with me for a moment: Over three billion years ago life began as a self-replicating molecule. This evolved into a self-replicating cell, which in turn evolved into a self-replicating multicellular organism with individual cells performing tasks for a given system. Multicellular life is a collective, if you will, an economy of divided labor. Evolution is a march up a staircase of functionality; molecules to cells to multicellular organisms. Civilization, too, is repeating this same pattern, marching up this same staircase of functionality. We have gone from caves, to cities, to the industrial revolution, the internet revolution, artificial intelligence and up and up. Science is perhaps the pinnacle of this societal evolution — the universe peering into the innerworkings of itself.
We can only get better at medicine in the future — it is writ large in the universe. But today the flaws in our health care system are substantial and systemic and will be obvious to future generations. We spend enormous amounts of money overtreating with drugs, procedures and surgeries that don’t move the needle much on our overall health. Future generations will instead focus on primary, preventative care — health care in harmony with the laws of thermodynamics. Technology will track outcomes. More convenient, at-home blood tests will be developed that encourage engagement, sustainability and a continuum of care. Cell phone apps will store results, allowing for a much more convenient interface between patients and doctors. COVID-19 has hastened the inevitable change to more efficient health care delivery through telemedicine — a system that is more user friendly, leverages technology to remove friction and is better able to facilitate primary, preventive health care. In time, we will get better at warding off the chronic diseases of aging and lengthening our health span. This is not terribly complicated. It could be implemented now, but we first have to fix the horribly broken incentive structure of our current health care system. If one were able to patent a simple three or four day fast a handful of times per year and put it into pill form it could potentially be a billion-dollar blockbuster drug. Same with a well-executed ketogenic diet or a quality exogenous ketone supplement administered preventively at midlife or when the first signs insulin resistance surface. The potential benefits of ketosis are enormous — initiating a cascade of changes that effects our entire metabolism — the chemical motion that quantifies our perception of time and defines our health; the chemical motion that is our vital spark. But the good news is that none of us have to wait for the system to catch up. Each of us can be a health care system of one.
https:// youtu.be/ 116WSn2WRLs