October 1, 2005 (Vol. 25, No. 17)
Individuals Need to Take Accountability for Their Health
I can not be the only person a little disappointed and frustrated with the fragmentation, volatility, and short-termism of what society calls its current global strategic agendas. In some cases these agendas seem to be at best, self-interested, in others, dysfunctional or entirely absent.
Today, we have many tools to help improve our material livesmore power, more connectivity, and more control over our human and natural environment than ever before, but we seem to struggle with many of the big issues.
We are adept at real-time decision-making, instant strategy, and sound-bite communication, but is anything happening today that we will look back to at the turn of the next millennium and say, That was important or That represented a step-change from which we are still benefiting?
There may be some things that our descendants may choose to remember us for. First, we have had the largest single improvement in material wealth in the history of the planet, in China and the Asia Pacific, accompanied by the worlds largest migration of people, from rural village to urban jungle driven by people wanting to achieve a better future for themselves and their children.
In terms of technology, we live in a whirlwind. Since 2000, the number of mobile phones outside North America and Europe has doubled. The available pages on the internet have more than trebled, and our accumulated computing power has quadrupled. Data, however, does not equal wisdom, no more than transmission equals understanding.
Paradoxically, while we have reached the current global limit in terms of availability and use of physical raw materials and living space, we find ourselves blessed with unlimited bytes and broadband, together with powerful new molecular biology. We need to use the glut of these invisible assets to help solve the visible limitations of the other and help tackle the major challenge of the next 50 years.
First, we have growing epidemics, centered on sub-Saharan Africa, not just of AIDS/HIV, but of malaria, polio, and measles. Second, access to healthcare is far from universal, and this is not confined to those countries that cannot afford it. We do not have to look far from here to find a medical system that provides its citizens with dramatically different levels of coverage and life expectancy.
The decline in the traditional strength of the family and social units is also a problem in western communities, and this phenomenon is migrating rapidly.
Staying within the bioscience field, we are placing great pressure on our macro-relationship with carbon, through increasing our fossil fuel consumption and decreasing the diversity and strength of the biosphere. I believe that the richness of our lives depends directly on the richness of the environment in which we live it.
The challenge for the industrial and scientific communities in the 21st century is to be highly inventive in designing strategies to meet everyones legitimate aspirations. We need to understand that the value of carbon lies in its organic complexity, not just in its combustion.
So, what can we achieve within the health care field? During the second half of the 20th century, the developed world achieved colossal advances in medical innovation focused around two distinct science streams.
On the one hand, pharmaceutical chemistry and related disciplines spawned important new therapeutics, developed by a high-performing pharma industry. On the other, medical devices and instrumentation advanced through precision engineering and material sciences.
Together, alongside improved education and living conditions, these innovations have saved, improved, and extended the lives of hundreds of millions of people. The danger now is that the success locks us into thinking that the same model will serve us as well in this century.
The most obvious limitation of 20th century healthcare is that it was directed at first-world markets and diseases. Despite having only 4% of the worlds population, the U.S. accounts for over 50% of the worlds health care market, and has a pivotal role in determining the prioritization of pharmaceutical research.
Tropical and niche orphan diseases have been largely neglected. I dont criticize the pharmaceutical industry for thisif only every industry were as successful in delivering what its customers want. But, I do question whether the shortcomings we face in healthcare are actually the sign of an incomplete and immature model? I think they are, not just industrially, but geographically, socially, and scientifically.
A new equation has arisen at the end of the twentieth century:
Longer life x multiple chronic co-morbidities x increased expectations = great pressure on healthcare resources.
These factors have also led to the perception, in the minds of major funders, that healthcare is one of societys greatest liabilities, whereas our health should be regarded and nurtured as our greatest asset, an undeniable dividend from a knowledge-based society.
Today, almost all our healthcare resources are focused on the treatment of post-symptomatic illness. Our model is based on allowing ourselves, through life-style, environment, latent genetic pre-disposition, or simple ignorance to develop serious disease.
The more sophisticated the economy, the more patients have access to intensive investment to optimize late-stage treatment outcomes. But, this arises at a time when the treatment options are narrower, costlier, and a successful outcome is less likely.
We need to challenge whether this narrow focus on Late Disease makes best use of our technological potential and is, in fact, the best way to help people preserve their greatest asset, their health.
So, how can we improve the healthcare model for the 21st century? As a prerequisite, we must move to a more geographically and socially inclusive healthcare universe. Our highest acute priority has to be to address the massive waste of life and potential in sub-Saharan Africa. This is a special case and requires far more than medicine. I applaud the new determination of the G8 governments to address this issue more seriously.
Beyond the acute crisis in Africa, our countries have to find a means of directing our long-term resources toward higher and more ambitious healthcare goals.
A combination of technology, education, and socio-economic change drove the improvements in therapeutics and public health in the 20th century. The same basic forces apply, but the key today is that the range of technologies now becoming available to us is truly transformational.
Previous industrial revolutions, triggered by step-changes in technology, required long periods of blood, sweat, and tears with immense physical labor, migration, and negative environmental impacts.
Today, we have a cleaner opportunity. The new revolution is still based on carbon, but instead of burning it, we gain our value from understanding its complexity and appreciating its great value. The emphasis shifts from extraction and consumption, to preservation and enrichment.
The motivating force of the first industrial revolution was production and transportation of physical goods. The driver of the new revolution will be health, both of ourselves and of our environment. Carbon becomes our partner, not just our fuel.
The 21st century healthcare revolution will be achievable without any of the physical traumas of previous social advancements. It will be led by information, the most mobile and educative of technologies, linked to new biological understanding.
A deluge of raw and turbulent information streams can be turned into much clearer fonts of decisional wisdom, which will allow us to move healthcare from a 20th century Late Disease model to one based on Early Health.
Early Health Model
We will need to place greater emphasis on the practical tools to help and motivate individuals to understand and maintain their own health. The keys for me are to adopt a holistic view of the individuals health and to act early, before symptomatic disease, or the factors that provoke it, are allowed to gain the upper hand.
This is much broader than just genetic-based medicine. It may sound surprising to hear a committed biomedical capitalist advocating a broader, public health-led model, but this is what is needed.
The Early Health model is a tremendous opportunity for all contributors to healthcare provision to unite in the design and delivery of new programs to discover and address the causes of ill-healthenvironmental, lifestyle or geneticthen address them with the individual before they become intractable, debilitating, and expensive.
Few of us will disagree with these broad preceptsbut where they come alive is when we consider the technological tools that are now appearing over the horizon. These technologies are different in their nature and scope from the levers that we had at our disposal even at the end of the 20th century.
First, we have biology, particularly genomics and its daughter sciences, where we seem to be heading inevitably via the proteome and the clinome, right through to the biome, envirome, and sociome.
Second, we have the bytes, the power for driving informatics processing, both micro (individual genetic and phenotypic) and macro (epidemiological).
Third, we have broadband, to provide the connectivity through cheap, infinite capacity mass communications that will link up our clinics to hospitals, patients to records, and the rural to urban environments.
Fourth, we have nanotechnology in all its manifestations and finally, we have the related discipline of bioengineering, which together offer great potential for delivering internal mechanisms to repair and replace worn and malfunctioning parts of our bodies.
The critical interplay however is between the first threethe fundamental building blocks of biology, bytes and broadband. This is transformational technology at its most powerful, equal in impact to the combination of iron, water, and coal that created the first industrial revolution.
DNA means little without massive analytical processing, and raw SNP analyses only become capable of transforming clinical practice through the connectivity of epidemiological data with individuals.
It is the forging together of biology, bytes, and broadband that will make a revolution that will not just be at the heart of healthcare, but of the interlinked development of our overall economy.
In the 20th century model, innovation spent years gestating in U.S. and European universities, followed by agonizing clinical and regulatory trials that only the advanced Western economies could afford to fund. Little surprise, therefore that this work focused on their priorities.
Other countries had neither the finances nor the infrastructure to participate, other than as passive consumers. In an age of biology, bytes, and broadband, these barriers and timescales are becoming less relevant.
Every human being has a genome of equal value and interest to both themselves and to society. Even the remotest settlements are installing satellite broadband. A $1 CD and a $20 mobile phone contain more storage and communication capacity than the first Apollo moon lander.
Information transfer is global and instant; the accessibility and power of the best diagnostic tools, critical to an Early Health strategy, has improved exponentially.
The cost profile is also changing. An Early Health model may actually be less expensive than maintaining, or building, a Late Disease health system. Investment in excellent, holistic, primary-care, with strong attention to lifestyle, environment, early diagnosis, and intervention, stands the best chance of limiting the development of expensive, debilitating late-stage diseases.
The investments required depend less on remote, tertiary hospital institutions and much more on community-based patient-centric services, enabled by integrated electronic health care records, remote real-time monitoring and the best possible screening and early diagnostic programs, tailored to the phenotype and genotype of the individual through well-validated epidemiological algorithms.
We should constantly ask, How do we take care to the individual? not How do we bring the patient into an institution?
We should also think radically about the relationship between the individual and their own healthcare. The 20th century relied upon a hierarchical relationship between a physician and a highly dependent, passive patient.
The patient had little medical knowledge, and abdicated responsibility to the doctor to stay healthy. In the Late Disease model, this means Please cure me now that I have been unlucky enough to fall ill. This is no longer a realistic relationship.
If we are to avoid an ever-increasing epidemic of Late Disease, individuals will have to take more accountability for their own healthsomething that it has been shown is extraordinarily difficult to do.
As we move further into the 21st century, people will be able to benefit from more personalized lifestyle choices, including, very shortly, genetic components, with which they will need to feel knowledgeable and empowered. Currently, society is ill equipped to take on any of this task.
Education in any society has always followed the level and type of knowledge that its leaders have wished each group to acquire. One thousand years ago, even without a formal education, there was a core knowledge set of religious observance, competence in agricultural or other necessary crafts, together with extensive life and health skills on how to look after and keep oneself alive, so as to be productive.
Today, students are expected to have knowledge of mathematics, science, humanities, and languages, but health figures no-where. Even a high-performing student, after up to 15 years of education, will have little knowledge of the workings of their own body, of disease processes, and of how to keep themselves healthy.
So, can we contemplate a society where the upcoming generation has a better understanding of their health in a practical, objective, and jargon-free manner? What better way to engage people to take responsibility for their health than to give them the tools to do so?