A common objection to funding longevity science is that longevity medicines, especially more advanced and expensive treatments like gene or stem cell therapies, could be very expensive, and only be available to the rich.

Depending on the cost, this could mean just those of us in high-income countries increase our lifespan, leaving poorer nations in the dust—or creating a dystopian cabal of immortal billionaires.

How expensive are longevity treatments likely to be, and how high is the risk of them exacerbating existing inequalities?

This article is adapted from the free chapter of Ageless: The new science of getting older without getting old, by The LI’s co-founder Andrew Steele. We want to make the Longevity Library the best resource for all things ageing-related, and will both create more articles on these ethical questions, and update this one with more data on things like billionaire investment in longevity companies soon.

How much will longevity treatments cost?

There’s a common perception that longevity medicines will be very expensive—but how much could these treatments actually cost?

Drugs which can be mass-produced as tablets are often very cheap to manufacture—metformin and statins, for example, cost pennies per pill. The reason many drugs start out expensive is partly governed by the system of patents, which gives companies exclusive rights to produce a particular drug or product for a period before allowing others to manufacture and sell it. Patents last twenty years, with a few caveats, meaning that pharmaceutical companies have a limited time to recoup their research costs; this is one reason why new drugs and treatments are often so expensive initially. Once they go off-patent and ‘generic’ versions can be produced, prices usually fall significantly.

The bigger worry is more complex therapies, which can cost far more than this. For example, a cancer treatment known as CAR-T cell immunotherapy has recently been making headlines for seeming to entirely eradicate blood cancers in some patients—and for costing almost $500,000 per course. If treatments this expensive were needed on, say, an annual basis, it would be fair to surmise that only the mega-rich could afford them.

However, costs at this level are unlikely to continue. Firstly, the actual manufacturing cost of the therapy—which involves extracting a patient’s immune cells, genetically modifying them, and reinfusing them back into the patient again—is probably ‘only’ a five-figure sum, rather than six. The full price incorporates recouping research and development costs by the drug company, profit, and a premium thanks to the largely private US healthcare system—the NHS in the UK has also started offering this treatment, paying an undisclosed sum per course which is less than the US sticker price.

The five-figure cost of CAR-T cell therapy comes because the procedure is still entirely manual, almost artisanal: highly-trained technicians, one literally watching over the other’s shoulder to double-check how many drops of chemicals they are adding to cells in a flask. (These stringent standards are applied because there’s a very high bar for safety and consistency for products destined to be used in people.) The therapy is brand new, taking its first baby steps outside the research lab environment where it was developed—if it turns out that the applicability of this kind of cell therapy is broader than the few cancers it’s been tried on so far, it is inconceivable that manufacturing costs will remain this high. This process is crying out for automation, which will make the therapy both far cheaper, and probably more consistent too.

CAR-T therapy and its ilk sit at the pinnacles of both expense and complexity—nothing discussed in Ageless is more involved than taking out cells, modifying them, and putting them back again afterwards. If these therapies cost tens of thousands while at the bleeding edge, I’m optimistic: it suggests that even the priciest treatments should cost thousands rather than millions. Therapies against ageing are also likely to be assisted by tremendous economies of scale. Because the market is literally everyone, rather than sufferers of a specific kind of cancer, there is both a greater impetus to optimise mass production, and a much larger population over which to recoup up-front costs. Naturally there is potential for some therapy not yet even on the drawing board to be more expensive than we can conceive today—but calling off ageing research thanks to a hypothetical risk of ludicrously pricey treatments seems premature.

Longevity science could help the poorest the most

It’s normal for all kinds of goods to be used by rich people in rich countries before being accessible globally. This is already true of medicines from basic vaccines and antibiotics to cutting-edge cancer drugs: while the former are now available in most parts of the world, expensive new treatments for cancer are unlikely to be found in clinics in the developing world any time soon. There is good reason to campaign for wider access to advanced treatments and to pursue research into neglected health problems which are particularly found in poorer countries—but speaking out against longevity science doesn’t advance either agenda.

There’s actually a reasonable case to be made that tackling ageing medically could help the world’s poorest. Global life expectancy is over 70 years, which means that most people in most countries will grow old enough to experience the diseases and dysfunctions of old age. Over half of dementia sufferers live in low- or middle-income countries—a figure that is projected to increase to two thirds by 2050, totalling 90 million people. And again, these are the figures for just one age-related disease.

These poorer countries’ healthcare systems simply lack the money and the infrastructure to deal with their ageing populations. We’ve been victims of our own success at improving global health: poorer countries around the world have had the good fortune to improve lifespans by rapidly rolling out cheap, successful interventions for ‘easy’ health issues, like infectious disease. Along with vaccines and antibiotics, one of the greatest triumphs in global health is basically salty, sugary water to rehydrate children with diarrhoea: this costs almost nothing, and is thought to have saved around 70 million lives. However, innovations like this mean that life expectancy gains have outpaced economic growth: these countries are now dealing with a booming cohort of older people, but without the cash to cope with the burden of expensive chronic diseases.

In high-income countries, life expectancy averages 81 years, and spending on healthcare averages almost $6000 per person per year. Globally, most people live in middle-income countries, which have an average life expectancy of 72—but an average GDP per capita of just $6500 per year. Healthcare at the level familiar in rich nations is, therefore, obviously untenable. This is an oversimplification (for example, labour costs are lower in poorer countries, which means doctors and nurses are cheaper), but it gives a sense of the scale of the problem: it will take decades of economic growth to solve it the old-fashioned way. Even more so than the rich world, poorer nations could benefit from treatments for ageing to avert a looming crisis in their healthcare systems—and it will be the moral duty of the rich world to ensure universal access.

Finally, it’s also possible to use treatments for ageing to address within-country inequalities. Headline life expectancies of 80-plus years in the rich world mask huge variations between regions within those countries, driven in large part by socioeconomic factors. While the interaction between poverty and health is incredibly complex, the end result from a biological perspective is that the less wealthy essentially age faster than the better-off. Higher rates of smoking, alcohol consumption, obesity, inactivity and so on, driven by a constellation of social factors, cause the same biological changes as accelerated ageing. This means that ensuring wide access to treatments for ageing would be a valuable adjunct to other policies aimed at reducing inequality.

Wider economic benefits of longevity medicine

The other factor is that treating ageing will mean there’s quite a bit more money to go around. The current cost of dementia, which includes health and social care, plus indirect costs of the sufferers being forced to give up work, or friends and relatives reducing their working hours to help take care of them, is estimated to be over $1 trillion worldwide, rising to $2 trillion by 2030. And dementia is just one of dozens of age-related conditions.

Alleviating even a fraction of the economic burden of these diseases would free up tens or hundreds of billions of dollars a year to cover the cost of the anti-ageing treatments that helped eliminate them. This also provides the incentive for governments to ensure these treatments are available to more than just the mega-wealthy—savings on healthcare costs and the benefits to the wider economy of keeping people healthy, active, working and spending will pay back the cost of their treatments.

Conclusion

It’s vitally important that we pay attention to equity as longevity therapies move from the lab to the clinic—and it’s a topic we’ll be researching and campaigning about here at The Longevity Initiative—but the scientific and economic analysis of the prospects for these medicines leads to a more optimistic outlook than is commonly assumed.