Dramatic Transformations in Health Care and their Implications for primary care 

Sohail Inayatullah[1]

Making sense in a time when Discovery science is rushing ahead of hypothesis driven science is not easy, especially when this new science is making mega "cents" – billions of dollars.

And a time when the nature of truth (from one to many), nature (seen as designable instead of God made or to live in peace with),  reality (challenged by quantum and miniaturized by nano) and society (connected via new digital technologies) are all undergoing revolutions that promise to make all of us strangers in a strange land, reason is hard to come by.

The dot.com boom is certainly being followed by revolutions in nano-medicine, pharmco-genomics and artificial intelligence …to mention a few of the forces changing health care.

The claims are grand.

Some of these claims are fueled by the promise of federal funding. In the USA, funding for nanotechnology has gone from 100 million in 1997 to 400 million in 2002 and around a billion outside the USA. Life science USA federal research funds have gone from 5 billion in 1970 to near and likely above 20 billion now.[2] In November 2003, the USA Senate has approved funding of 3.7 billion dollars over four year to fund nano-tech research.[3]

Underneath this of course is the reductionist worldview, searching for the one factor that will somehow solve our health predicaments, and, it seems deliver us from death, or least from living a live of misery and pain.

And way below, in the unconscious lies the true source – the search for the silver bullet, the fountain of youth, the final solution, and the hope that it is not Pandora’s box that is being opened, that as Professor Ken Donaldson of the University of Edinburgh warns: “Nano-technology threatens to generate new hazards in the form of toxic molecules that can enter the lungs.[4]

But the promises are dramatic and utopian.

Writes Robert Frietas in his book Nanomedicine 

“Once nanomachines are available, the ultimate dream of every healer, medicine man, and physician throughout recorded history will, at last, become a reality. Programmable and controllable microscale robots comprised of nanoscale parts fabricated to nanometer precision will allow medical doctors to execute curative and reconstructive procedures in the human body at the cellular and molecular levels. nanomedicine will employ molecular machine systems to address medical problems, and will use molecular knowledge to maintain and improve human health at the molecular scale … “[5]

Nano surgery … nanomachines flossing and brushing, identifying and destroying pathogenic bacteria while allowing the harmless flora of the mouth to flourish in a healthy eco-system. … nano systems in your body,  proactively guarding against cancer and other diseases.

Continues Frietas:

“Nanomedical physicians of the early 21st century will still make good use of the body's natural healing powers and homeostatic mechanisms, because, all else equal, those interventions are best that intervene least. But the ability to direct events in a controlled fashion at the cellular level is the key that will unlock the indefinite extension of human health and the expansion of human abilities”[6]

Ultimately the would lead to the pharmacy in your body, suggests Clem Bezold of the Institute for Alternative Futures.[7] 

But it is not only nano-medicine that is spearheading a different future. The promise of health bots, once imaginary, are now at the prototype stage at MIT. 

Health bots are health coaches - always-on wearable computers.  They will provide individualised and immediate feedback to our behaviour, for example, letting us know caloric intake, the amount of exercise needed to burn off the pizza we just ate.

They will also let us know the make-up of each product we are considering purchasing, helping us to identify allergies, for example.

These intelligence computer systems would be reflexive knowledge systems, learning about us and our preferred and not so preferred external environment.

These will be powerful health coaches provided by your health-care provider, which will not only aid diagnosis but also reinforce pursuit of your chosen health goals.  These expert systems, or electronic personal guides, will tailor the information to your own knowledge level, interest level, and learning style, as well as those of your family members, each of whom would have a personal electronic ‘health coach.’  If you are genetically or otherwise inclined to heart disease, your coach will encourage specific preventive measures.

This is the health professional on a wrist.

What is crucial is these bots will be: customized, immediate and reflexive – that is connected and learning, and individualized.

But if this was not enough, along with nano and bot futures, there is emerging field of pharmacogenomics.

Pharmacogenomics [8]”is a science that examines the inherited variations in genes that dictate drug response and explores the ways these variations can be used to predict whether a patient will have a good response to a drug, a bad response to a drug, or no response at all.”

Write proponents.

“Right now, in doctors' offices all over the world, patients are given medications that either don't work or have bad side effects. Often, a patient must return to their doctor over and over again until the doctor can find a drug that is right for them. Pharmacogenomics offers a very appealing alternative. Imagine a day when you go into your doctor's office and, after a simple and rapid test of your DNA, your doctor changes her/his mind about a drug considered for you because your genetic test indicates that you could suffer a severe negative reaction to the medication. However, upon further examination of your test results, your doctor finds that you would benefit greatly from a new drug on the market, and that there would be little likelihood that you would react negatively to it. A day like this will be coming to your doctor's office soon, brought to you by pharmacogenomics.”[9]

Those in the field do not see these new developments as minor historical events, rather a renaissance is here 

Of course, we are not even discussing gene therapy or germ line intervention  - the use of genetically altered eggs or sperm to correct or improve the genetic makeup of a resulting baby.[10] This is not just genetic surgery but germ line therapy or the modification of heritable characteristics.[11]

WHAT DOES IT MEAN?

Now what does this all mean? There are endless websites on the subject now, stunning documentaries. As well, technological and biological transformation are not the only game in town. Research consistently suggests that what is needed is more walking, and better diets.[12] And we do not need to invoke Marx to remind us of the foundational imprinting of class in deciding our life chances. And in societies where patriarchy is dominant, gender certainly defines life chances.

But perhaps as important as the search for more than one factor, ie going beyond the silver bullet theory of the universe, is seeing genes (and the nano world as well) as far more fluid.  

Writes Matt Ridley:

“In the new view, genes allow the human mind to learn, remember, imitate, imprint language, absorb culture and express instincts. Genes are not puppet masters or blueprints, nor are they just the carriers of heredity. They are active during life; they switch one another one and off; they respond to the environment. They may direct the construction of the body and brain in the womb, but then almost at once, in response to experience, they set about dismantling and rebuilding what they have made. They are both the cause and the consequence of our actions”[13]

THE FUTURE

Thinking about the future should be neither risky nor arrogant, but systematic and rigourous. There are a range of tools that can be used to make the future more sensible.

First is the Futures Triangle.

That is

1.What are the pulls of the future – the images that define where we are going./

2. What are the pushes – the quantifiable drivers?

3. What are the weights – the structures or patterns that make change difficult.

In our case, the images are obvious.

1. Long life, healthy life via human design and technological intervention
2. A better, higher quality of life via social policy: access to health dollars, individual behavior change by following the evidence, in most case, this now means, more exercise, a better diet, and a more responsive and responsible health system.
3. The slower life, guided not by technological advancements but my communication – talking to friends, nature, the gp, and even angels. Quality is first here, it is not doing more but enhancing the immune system by changing society’s views of progress and quantity.

The drivers include economics, an aging society, funding for high-tech interventions, globalization..

Finally, the weights too are legendary – class, gender, the medical system (professional, bureaucratic, market, state controlled for example) and of course evolution.

What is remarkable now is that the weights are no longer seen as immune from change. Germ line intervention, for example, seeks to change the direction of evolution. Digitalization, nanoization, both seek to re-represent our selves.

But which image will become dominant.

Health Care Futures

TECHNONOLOGICAL INTERVENTION

SOCIAL POLICY INTEVENTION

WORLDVIEW TRANSFORMMATION

           

 

 

 

 

 

 

 

 

 

 

 

 

 

PUSH OF THE FUTURE                                                                              WEIGHT

 

GLOBALIZATION                                                                                            CLASS           

AGING                                                                                                 MEDICAL SYSTEM

SCIENCE AND TECHNOLOGY

What the triangle suggests is that the future is not created. There is a tension between the pushes – the technological imperative and costs associated with it – and the pulls and weights.

What then is the future, which image if likely to win out? Will the weights dominate? One way to assess the future is to develop scenarios, or stories of the future. Four are articulated. They are based on the images and the weights.

SCENARIOS

1. SCIENCE AND TECHNOLOGY PENETRATES AND TRANSFORMS SPACE AND TIME, NOT TO MENTION EVOLUTION

This is very much the extreme future. Driving it is research in the area – the billions from drugs sales that are likely to result, and the real possibility of major breakthroughs.

*          The discovery  in mice of a gene that causes the congenital birth defect spina bifida, is the latest event that raises hopes for the development of genetic testing and better treatment for the condition in humans.

*          The Fred Hutchinson Cancer Research Center said it is in a collaboration effort with Intel Corp. of Palo Alto, Calif., in which Intel will provide its nanotechnology to the center for cancer research. Intel will build a Raman Bioanalyzer System at the Fred Hutchinson Center in Seattle to launch the collaboration, according to a press release. [14]

“The instrument is normally used to detect microscopic imperfections in silicon chips. The cancer research center will beam the bioanalyzer's lasers onto medical samples, such as blood serum, to create images that reveal the chemical structure of molecules, helping to analyze, diagnose and prevent cancer.

"This collaboration is a unique and exciting interaction," said Lee Hartwell, director of the center. "Biologists have never before had such a method for studying the molecular structure of biology. This is true discovery-based research; we don't know what we will see or learn."

l       Mihail Roco, senior advisor for nanotechnology to the USA national science foundation says they hope to eliminate all cancers by 2015 using nano-technology. He says: “this is not a dream but a vision based on a well defined strategy.”[15]

Indeed, one can even begin to imagine the creation of a new species – that is, human will metamorphose. The result will be what Alan Goldstein, director of Biomedical Materials and Engineering and Science at Alfred University in New York, calls, Homo Technicus. “Homo Technicus will be a fusion of biology and technology at the atomic level. Its living and non-living materials will be indistinguishable.” [16]And in the next 100 years, the nanotechnology revolution is laying the foundation for the end of Darwinian evolution.

What then for primary care? The following five impacts are likely:

1. GP’s become truly quaint or they reinvent themselves.2. The system in itself will become far more discovery research driven.3. It will become far more complex, unless ways are found to simplify information to patients. 4. The expectation of patients will dramatically increase, and when unmet, it will likely be the GP who will be blamed since they will be the first points of contact. 5. Primary care will also deal with the mistakes – the therapies gone wrong, or gone right but having created new problems, the unknowns that are likely to result. 6.Require continuous retraining. Lifelong learning however will change as many current GP functions will be eliminated by artificial intelligence.

2. SCIENCE AND TECHNOLOGY ARE PART OF A LARGER MULTIFACTORIAL APPROACH TO HEALTH POLICY

Other factors are considered just as important – diet, lifestyle, class, gender and even city design. With recent studies indicating that obesity is directly related to suburbanization, health can no longer be considered an externality. One can even join class action suits now if one is obese and can link it to city design.[17]

And with architects arguing that building design – can actually enhance or harm health – and organizational specialists arguing that organizational culture directly relates to days sick and research suggesting that those who can deal with emotions more effectively have better physical health,[18] merely focusing on genetic or nano solutions is a mistake.

Moreover, while “the science of pharmacogenomics will provide an increased level of accuracy in selecting specific drug therapy for individual patients, it will not replace the art of clinical judgment in practice because of the confluence of social, behavioral, economic and environmental factors.”[19]

The GP in this future is the integrated doctor. She is the listener, the friend and the wise counsels, who reminds the patient to look at all the evidence, not just the most sensational, and who looks underneath the tip of the iceberg, for the social and design factors, and the worldviews individuals hold about their health.

The GP as well becomes the knowledge navigator, suggesting diet alternatives, and when appropriate, the  Digital Angel – a tiny transmitter monded or implanted under the skin, sends a patient's medical information and precise location to a monitoring system via global-positioning satellites (GPS).

Ultimately, it will be the Multi-door health centre that will thrive in this future.[20] However, given funding mechanisms in most countries, this is not easy to do, that is, pressures from corporatization. What is clear is that new social innovation is required. GPs must imagine the future they collectively desire, and advocate for that future, to government, to patients and other stakeholders in the health field.

3. THE SCIENCE AND TECHNOLOGY REVOLUTION DIVIDES SOCIETY

This unfortunately is the most likely. In the extreme case, life expectancy differentials could be 100 years or so, the wealthiest extending their lives to 120 -130 and the poorest dying in their 30s.

The new technologies will not be cheap for patients. And with an aging population and the development of the security state, fewer funds will be available for equalizing society. Globalization qua corporatization/privatization will not make things easier.

Primary care will suffer no doubt. GPs will deal with those who do not have access to the latest technologies. Their days will be long and with little reward, since those at the bottom may see that it is the structure of inequity that has placed them in the doctor’s office.

Of course, health centres will thus likely corporatize, as the corner store or back to traditional values GP image will disappear.

These divisions will be global, within nations and within the traditional divides of rural/city, but now exacerbated.

The second order impacts however are likely to see the continued division between health professionals and the state, arguing on different health and social policy lines, not to mention insurance.

The rich, of course, will use both the new genomic, nano and bot technologies but as well all the softer variants – massage, homeopathy, etc.

The poor … well  relative deprivation will make life seem nasty, brutish and short. Maybe for the sake of equity, the State will come in and monitor, regulate – generally control – birthing, that is, not the village rearing the child, but the State.

 

4. SCIENCE AND TECHNOLOGY REVOLUTION IS INCREMENTAL, MOST THERAPIES MISS OR ARE TOO DANGEROUS BUT A FEW CHANGE OUR HEALTH POSSIBILTIES

In this future, oversell is the defining word. Once few breakthroughs result, and that revolutions become instantly naturalized – like the television and pc, part of daily life – they hype will disappear. As well, breakthroughs will be short lived, as gene therapy is considered now. Or have too many side affects. As we know with the computer revolution, depression, anomie, and immediate disconnection (while connected to far away, have been unintended consequences)

Again, it will be the burden of primary care to sort out the mess. What has gone wrong? Expectations unmet. Costs overblown.

But individuals will find solace in daily life, and at the end of the day, it will be neighborhood physician and pharmacist who will diagnose and provide advise on what to do next.  Of course, by the time they arrive at the health centre, they will have already read hundreds of websites – and the clever GP will be engaged in e-consulting – and expect the GP to advise which one is real.

Which future is likely? 

At this stage it is difficult to tell. My preference is for the multi-factorial future, however, our search, especially in the West, for bottled nirvana, is likely to see the first scenario triumphing, which will in turn lead to a divided society.

At this stage, it will not be nano-cures that are needed but real systemic change. And it will not be technology or discovery science that will provide that, but medicine as a social movement, focusing on regaining the public trust …