Listening to Resveratrol
Could the famous ingredient of red wine herald a new era in medicine?
We may be on the brink of an important and unrecognized change in medical technology development, one that raises important questions about the future of medicine and human health.
How will we test the efficacy and safety of new life-prolonging technologies?
Currently our drug development and approval systems aim at disease-specific treatments. Indeed, the Food and Drug Administration approves medications only for specific indications, and "mortality," a universal condition, would seem unlikely to qualify under the current system. Further, if senescence begins in one's 30s but the outcome (that is, death) can be measured only in one's 70s or 80s, how will researchers be able to perform timely clinical trials in humans? Sinclair and others hoping to commercialize anti-aging elixirs have devised a strategy of testing agents for the treatment of age-related diseases, such as specific forms of cancer, Alzheimer's disease and heart disease. Yet Sinclair also reports that he started taking resveratrol in his 30s-a reasonable course for an anti-aging agent-but such use will remain "off-label" unless we create a new system, including reliable surrogate outcomes, to test and approve such compounds for this purpose.
How much will life-prolonging therapies cost-and who will pay?
Health insurance is based on the principle of risk pooling. Because nobody can be certain that they will remain healthy, the disease-free are willing to share the cost burden with the sick, who often are unable to handle the expense of their own care. This approach works with disease-oriented treatments in which risks are pooled across those people who could and those who actually do develop an illness. But if resveratrol-like drugs are recommended for everybody over 30 at risk for mortality (a universal condition), there would be no risk pooling; insurance premiums for everybody would just go up by the drugs' cost (plus an administrative fee).
Although drug pricing strategies remain a deeply held trade secret among pharmaceutical companies, there is little doubt that there will be consumers willing to pay very high prices for life-prolonging elixirs, even for drugs with a relatively small incremental benefit. The optimal pricing strategy for such agents might put them well out of reach of the poor and possibly also some of the middle class. Since multiple cellular pathways are probably involved in aging, there are sure to be multiple medicines in our anti-aging cocktail. The rich have always lived longer and healthier lives than the poor, and new lifespan-extending technologies could widen this gap.
Should access to resveratrol and other such agents be an entitlement? Many societies see access to health care to cure diseases and rescue patients from premature death as a matter of equity. What ethical attitude will we take toward 21st-century medical technologies aimed at challenging the limits of our natural lifespan?
How will lifespan-prolonging therapies affect population growth and demographic structure, and what will be the consequences?
In the past century, disease-specific medicine reduced mortality at all ages, including the economically productive years between one's 20s and 60s. But the rectangularization of the mortality curve implies that life-prolonging therapies will add years only at the end of life. Unless there is a shift in the retirement age, 21st-century medical innovation will have an even more dramatic effect on the dependency ratio (a measure of the portion of a population composed of those either too old or too young to work). Maintaining retirement as a widespread option at around 65, already an economic stretch, undoubtedly will become untenable. The price of longer life will almost certainly be a longer work life.
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