Dramatic Transformations in Health Care
and their Implications for primary
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
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.
In November 2003, the USA Senate has approved funding of 3.7 billion dollars
over four year to fund nano-tech research.
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.
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 … “
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.
“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”
Ultimately the would lead to the pharmacy in your body,
suggests Clem Bezold of the Institute for Alternative Futures.
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
These intelligence computer systems would be reflexive
knowledge systems, learning about us and our preferred and not so preferred
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
But if this was not enough, along with nano and bot
futures, there is emerging field of pharmacogenomics.
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.”
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.”
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.
This is not just genetic surgery but germ line therapy or the modification
of heritable characteristics.
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.
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”
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.
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.
- Long life, healthy life via human design and
- 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.
- 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,
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
Health Care Futures
SOCIAL POLICY INTEVENTION
PUSH OF THE
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.
- 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.
“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."
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.”
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.”
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
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.
- 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.
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,
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.”
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.
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.
- THE SCIENCE AND TECHNOLOGY REVOLUTION DIVIDES
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,
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.
- SCIENCE AND TECHNOLOGY REVOLUTION IS INCREMENTAL,
MOST THERAPIES MISS OR ARE TOO DANGEROUS BUT A FEW CHANGE OUR HEALTH
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 …
Gary Stix, ”Little Big Science“
(September 16, 2001), Scientific American.com
www.smalltimes.com. “Researcher warns of toxic threat from
nanotechnology,“ accessed November 19, 2003.
See Clement Bezold, Will heart disease be eliminated in your lifetime?
The best of health futures, Futures Research Quarterly (Summer
A gene is a functional segment of DNA that
specifies, or assists in, the expression of a particular phenotype.
Therapy, according to the Oxford dictionary, is a "curative medical
treatment"; this implies the remedial treatment of disease.
Therefore, gene therapy is, in an elementary sense, a remedy for disease
and, in light of trends in preventive medicine, a method for preventing
disease by genetic manipulation. These methods fall into two broad
categories -- somatic-cell therapy and germ-line therapy.
Somatic-cell alteration is
a form of genetic remedy that does not affect gametes but simply changes
a diseased person's form by manipulating the somatic cells that cause a
disease. This form of therapy involves altering the genetic makeup of
only those cells that cause disease -- it can be considered "genetic
The second type of genetic
therapy involves permanent changes to a person's genome by germ-cell
alteration. This procedure, known as germ-line gene therapy (GLGT, or
genetic engineering), results in modification of heritable
characteristics. These changes can be passed on to progeny.
The former therapeutic
practice appears to require relatively little ethical consideration, but
the latter has created dilemmas for those making professional, social
and personal ethical judgements. Some authors have chosen to distinguish
between GLGT for treatment of disease versus GLGT for enhancement
purposes.[2,3] I consider both under the same heading, as the latter
represents the fullest potential of the former. I wish to consider
whether genetic engineering in humans ought to be practised.
problems raised by genetic engineering stem from societal and individual
implications, issues of control and the biologic impact of genetic
manipulation. Various ethical principles, including autonomy,
beneficence and nonmaleficence, can be invoked to delineate the nature
of these factors.
See Sohail Inayatullah and Jennifer Fitzgerald
"Gene Discourses: Law,
Politics, Culture, Future," Journal of Technological Forecasting and
Social Change (Vo. 52, No. 2-3, June-July, 1996), 161-183.
For debates on the long term futures of the ethics of genetics, see,
www.futurefoundation.org. The work of Gregory Stock is of particular
interest (http://research.mednet.ucla.edu/) as is, from an Islamic
perspective, Munawar Anees. www.dranees.org
And yet one more study confirms this. A survey released yesterday by a
leading cancer agency was cited as suggesting that millions of Canadians
could decrease their cancer risk by eating more fruits and vegetables,
exercising more often and keeping the extra pounds at bay. Gloria
Galloway, Globe and Mail, Page A7 December 17, 2003.
Matt Ridley, What makes you who you are, Time, june 2, 2003, page 58.
www.smalltimes.com. Steve Mitchell, “Nanomedicine
vital to finding a cancer cure.” UPI. Accessed 1/11/2003.
healthy body: study. Accessed November 2003.
Op cit pharmcogenomics
For more on this, see Sohail Inayatullah, Trends transforming the
futures of General Practice and Practitioners:Or is there a doctor in
your future(s)? www.metafuture.org