The biotech and pharmaceutical industry is full of people who went to the top universities, live in the fanciest neighborhoods, and work for brand-name companies. But this industry needs to start thinking more about millions of people who are mostly an afterthought today. I’m talking about people who live in America’s small cities and rural areas.
This isn’t something I’ve personally thought about very much, since I spend most of my time zipping between the toniest ZIP codes in the U.S., where most healthcare innovation occurs. But the idea dawned on me this past week after I traveled to a place just 270 miles from home, yet a world away—Spokane, WA (population 208,000). It became even clearer over the next couple days during a trip to one of the top biotech clusters—San Francisco.
The way things work today, people in the top biotech clusters don’t talk to folks from small cities and rural America. Companies developing new drugs, devices and diagnostics tend to congregate in a few hubs like San Francisco, Boston, and San Diego. Folks in these places cultivate relationships with “thought leaders” at major urban medical centers like Massachusetts General Hospital in Boston, UC San Francisco, or Memorial Sloan-Kettering Cancer Center in New York. The companies hope that these thought leaders will run a stellar clinical trial of a new drug, tout the result at medical meetings, and influence peers to prescribe it once it reaches the market. Patients with money and good health insurance are often the ones fortunate enough to see these doctors, and get access to treatments that offer new hope.
It doesn’t have to always work this way. Having so many trials routed through the major urban medical centers is expensive. It also taxes the time and attention a given “thought leader” can provide to the testing of any one product. And it puts drugmakers in a fierce competition with one another for a finite number of patients who can enroll in a study, of, say, a new lung cancer treatment. When drug companies think about alternatives to those bottlenecks, such as ways to speed up clinical trial enrollment and save money, they often think first about going to China, India or Eastern Europe—not places closer to home like Spokane.
But guess what? There are good reasons for biotech and pharma companies to take a closer look at lower-cost “second cities” in the U.S. The doctors who live and work there, and who often serve rural communities, may not get their names in the New England Journal of Medicine like the big guys. But the small city doctors often did get their training at top-notch medical schools, and know what they are doing. Many of them have long-term, trusting relationships built up with their patients, who have long-term roots in their communities. These doctors regularly see patients who struggle with the major epidemics on the radar of Big Pharma—conditions like diabetes, obesity, cardiovascular disease, cancer, autoimmunity, and neurological disorders.
It stands to reason that U.S. doctors off the beaten track are both willing and able to conduct good clinical trials. And if they are included in clinical trials early on, the odds are high they will champion new treatment strategies pushed by the drugmakers.
Still, I rarely if ever hear biotech leaders talk about engagement with small towns and rural areas. So I checked around to see if maybe there’s some level of engagement in small cities and rural areas that I’m not aware of. I asked Maureen Cronin, the senior vice president of R&D at Cambridge, MA-based Foundation Medicine, about the extent of engagement between drug companies and small cities. She knows something about this question, having spent nine years previously at Redwood City, CA-based Genomic Health (NASDAQ: GHDX) where part of job involved outreach to marginalized communities in the U.S., including Spokane, WA, Eureka, CA, and rural areas near Kansas City.
Cronin, who got her doctorate from UC San Diego, described her small town outreach efforts as an eye-opening experience.
“The doctors there are savvy, up-to-date on information about genomics, the latest tools, and targeted therapy,” Cronin says. “The problem is that mostly they are struggling to get access to basic resources.”
For example, Cronin says she has gotten to know three bright young oncologists in Humboldt County, in far northern California, who trained at one of the top med schools—UCSF. Humboldt is one of the poorest places in the Golden State, where unemployment is high, chronic disease is high, and insurance coverage is low. Doctors there struggle to share resources like mammography machines, or radiation therapy tools.
Drug companies often ignore areas like this, assuming that few patients are able to pay for new medicines. But small towns have one thing that’s in short supply in the big city: doctors have strong connections to their patients, Cronin says.
One company I’ve written about recently has seen the differences between “thought leaders” and community leaders. Waltham, MA-based Alkermes (NASDAQ: ALKS) won FDA approval last fall for a new drug designed to help wean people off addictions to opioid-based painkillers. It was tested, like most new drugs, at major urban medical centers.
Once cleared for sale, an interesting thing happened. The medical thought leaders who are familiar with the Alkermes product, as it turns out, never see the majority of patients in the U.S. suffering from addictions. Yet local health officials, drug courts, and counselors from around the country—where there was little familiarity with the Alkermes drug from clinical trials—started calling the company to try to get their hands on the new drug to test how it could help in their communities.
Addictions to opioid-based painkillers like oxycodone are a serious problem in rural and urban parts of America. Alkermes is now working on a number of pilot projects around the country to help local officials ask questions about whether its drug improves health outcomes, reduces repeat criminal offenses, saves money for local healthcare and criminal justice systems, or some combination of all of the above. Much of the commercial success of this product hinges on how well Alkermes engages with physicians and officials in these territories.
Alkermes CEO Richard Pops explained in a thoughtful note to me why his company felt it was necessary to follow this path to the market. Clinical trials are highly regulated, and require staff with training and experience in running them according to strict protocol, Pops says.
“Because the lifeblood of our companies is the data we generate, we tend to be highly selective in choosing sites, particularly for pivotal studies comprising the core of the new drug application submission,” Pops says. “For these reasons, we tend to run studies in places experienced in running studies if possible. They understand good clinical practices (GCP) and, in addition, tend to have more patient flow, which speeds recruitment.”
Now that Alkermes drug is on the market, it has had to reach out into a lot of new communities. “We have had to build our understanding of the real world treatment of alcohol and now opioid addiction, which is happening in all kinds of different venues outside of where we may have conducted trials,” Pops says.
I hope for the sake of people in large swaths of the country that companies like Alkermes can figure out how to effectively bridge this gap. Pharma and biotech companies have products that could make a positive difference for many people if used properly. Small cities and rural America shouldn’t be considered flyover country. It’s time to start thinking about the people who live there as valuable customers and contributors.
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