Medicine’s new frontiers

Advances offer a healthier future for all, but putting them into practice will not be easy, writes Liam Donaldson

Will the babies born in 2017, as they move through their adult years, be the first generation in which the ageing process is slowed down by medical intervention? Will they be the first generation to benefit from cancer being a curable disease? Will they see their memories being transferred from their brain and become video-clips on a computer? Or will it be their children or their grandchildren who are the beneficiaries? Such changes and more will surely come; it is a matter of when, not whether.

Imagining transformations like these that are over the horizon and, so, not yet on a visible path to realization, is one way of thinking about health futures. Another way is to delve more deeply into the consequences of the scientific and technological advances that are already infusing our world. They are little understood by the public and those who have already become patients.

The mapping of the body’s genetic code, the detailed understanding of disease processes at the molecular level, the use of stem cells to repair damaged or diseased tissues and organs, the harnessing of robots to perform surgery, the mining of vast databases to find the causes of disease, the deployment of monitors and miniature devices to track an individual’s health and vital signs, are all currently being grappled with as their significance in our future health and healthcare becomes clearer.

As the great infectious diseases of the 19th and early 20th century were no longer major killers, no one really predicted the growth of the diseases of civilization

As these current medical frontiers unfold into a new future, they will undoubtedly lead to more illnesses becoming curable while the onset of other diseases will be delayed or prevented. They will lead to more effective, better-targeted medicines. They will produce a fundamental shift in the balance of power in medicine; patients will hold much more information about their condition and will no longer tolerate being passive, and deferential, recipients of care. Indeed, there is every likelihood that informed citizens, armed with extensive data about themselves from their smart devices, will find alternatives to assist them in interpreting what they hold. The traditional doctor-patient relationship could be scattered to the four winds.

Healthcare systems are becoming larger and ever more complex bureaucracies, subject to frequent changes in leadership, structure, and financial regimes. Britain’s National Health Service is amongst the worst examples of this, with a history of more than 20 reorganizations since the 1970s. Even I, who worked in its higher echelons for 30 years, have difficulty in understanding it now. And as I travel around the country, I find few staff who can give a clear explanation of how their service works. It has become a Tower of Babel.

There can be little doubt that the range of scientific and technological advances that I have described will be disruptive to health systems around the world. Even without their paradigm-shifting force (in digital, technological and biological terms), the gentle, but lumbering, giants that comprise modern health systems have been slow to adapt to changing needs and public expectations.

Some, including the National Health Service, have been associated with major failures in the implementation of large-scale information technology projects. Many strategic challenges have been ducked or merely agonized over. For example: shifting care outside hospitals, integrating between primary and secondary care sectors, supporting people with chronic diseases to manage their own condition, preventing more illness and reducing the amount of harm caused by healthcare have been policy imperatives for two decades. Yet, despite their centrality to the sustainability of healthcare, there have been few signs of transformation.

For the first time, a new strategic force is beginning to reshape healthcare: the power of modern technology. Its long-term impact is both exciting and unpredictable. It is no accident that companies such as Google, Apple, IBM and Facebook have begun to explore the health space; for example, the artificial intelligence capability of IBM Watson has been focused on decision-making in lung cancer treatment at the Memorial Sloan Kettering Centre in New York while Google DeepMind is examining eye scans, at Moorfields Hospital in London, to find hitherto unrecognized precursors of blindness.

These companies, and the myriad of start-ups in their orbit, see uncharted territory for discovery, analysis and application in areas that traditional health systems are too slow and unwieldy to exploit.

In response to the existing challenges, and the emerging ones, leaders of today’s health systems can no longer rely on a wait-and-see management philosophy. They must rethink, redesign, and reinvent.

A third way of thinking about health futures is to work out how many of today’s problems and challenges will persist or, even, worsen. The health of the British population has improved greatly since the middle of the 20th century, but the foundations were actually laid by events in the second half of the 19th century.

Its architects, who built a healthier future for the nation, were scientists, public health pioneers, and sanitary engineers. The towns and cities of the Industrial Revolution were not just manufacturers of iron and steel, they produced illness, disease, and human degradation on an industrial scale too. Lives were brief, children’s funerals were a frequent occurrence, and hospitals were death traps as fatal sepsis after surgery and childbirth stalked their wards and corridors.

The discovery of germs and the realization that poor sanitation, filth, and overcrowded dwellings spread infections and ignited epidemics of diseases such as cholera, smallpox, and typhoid demanded action. The so-called sanitary reforms, comprehensive vaccination, and the use of antisepsis in care led to greatly reduced infant and child mortality and hence longer lives. Antibiotics and the benefits of modern hospital care came later but it is fair to say that public health reforms were the game changer.

As the great infectious diseases of the 19th and early 20th century were no longer major killers, at the foundation of the welfare state in 1948, no one really predicted the growth of the diseases of civilization. Today, conditions such as cancer, heart and respiratory disease, stroke, dementia, mental illness and diabetes dominate population health.

The same transition in the disease burden is now occurring globally. The World Health Organization estimates that 80 per cent of deaths from chronic diseases now occur in low and middle-income countries.

It is the sheer volume of people living with chronic illnesses, often a number of them, that places so great a burden on health and care services and on public expenditure. The numbers living to older ages where multiple diseases and frailty are common compound this. Nor does the burden fall evenly. Both nationally and globally, the health of the affluent is markedly better than that of the socially and economically disadvantaged.

Whether this dominance of long-term disease is a firm fixture of health in the future depends on the determination of governments, citizens, and families to commit to taking some of the difficult decisions on lifestyle, behaviour, and social policy that will be necessary.

Solutions are complex to implement, long-term, often contentious and politically challenging. Action often gets caught up in arguments about the ‘nanny state’, a label that politicians seem to fear being attached to them more than any other.

The truth is that many of today’s health problems, such as obesity and diabetes, have such a range of causal influences that they need government action, regulatory measures, and individual responsibility if progress is to be made. The benefits of this multi-stranded approach are emerging with the fall in the proportion of people smoking cigarettes as strong government action − smoke-free legislation and introducing plain packaging − are combined with health education.

Retaining a global perspective on health is important and not just on humanitarian grounds. The danger that weak health systems pose to other parts of the world is real and present. The outbreaks of Ebola fever that began in West Africa in 2014 rapidly overwhelmed health systems that were already weak. They generated fear and mistrust of the authorities, leading some communities to hide family members who were ill. They killed members of an already inadequate medical and nursing workforce, adding to the grave problems of the countries’ infrastructures. Ebola came within a hair’s breadth of becoming a global catastrophe; it generated worldwide concern, heavy media coverage, large-scale external aid, as well as numerous crisis meetings of political leaders and experts.

Many low and middle-income countries still have weak health systems with fragmented service provision, and current or recent political instability. Expanding coverage to the poorest populations and generating finances for health systems are problems that are being addressed by the initiative of the World Health Organization and the World Bank to achieve the goal of Universal Health Coverage.

In addition to the humanitarian and bio-security arguments for the high-income countries of the world to help strengthen weak health systems in the poorer parts of the world, there is the strong relationship between health and prosperity. Health improvement has a core role in nation-building. The link between investment and outcome may be complex, but the case for doing it is strong.

There is also the gain in soft power; for example, those trained by the British medical Royal Colleges are in key roles right across the world and most have retained a deep loyalty to the country and its values. Following the vote to leave the European Union, it is far from certain that this can continue. Existing shortages of nurses and doctors in the NHS could worsen and the country’s global leadership role in medical research could be degraded.

The future health of populations can be shaped, as it has been in the past, by clear statements of intent, bold, coordinated action, and strong systems and governance that promote health as a fundamental value and right for everyone.

Changing the future prospects of the poor and disadvantaged, who are denied most of the opportunities for health by their circumstances, is the biggest challenge of all.  The rapid developments in technology, medical science, and information, both in train, in prospect, and as yet unforeseen will be a big part of the future for health and healthcare. Their innovations will disrupt as well as transform. The poor record of health systems in rapidly adapting to change will demand the banishment of servants of the status quo if the full potential of this exciting future is to be realized.

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