by futurist Richard Worzel, C.F.A.
To begin, I need to impart a sense of the dramatic changes that are going to occur in health care over the next quarter-century. Intellectually, we all know that there are going to be a lot of changes, and significant ones to boot. Emotionally, though, I really doubt if any of us believes, in our heart-of-hearts, just how dramatic these changes are going to be.
I think we would all agree the rate of change is accelerating, as it has since the beginning of the Industrial Revolution. I think most people would also agree that the pace of change was substantially faster at the end of the 20th century than it was at the beginning. I’m going to arbitrarily say that it was at least 6 times faster, and that change will be at least 6 times faster over the next 25 years than at the beginning of the 20th century. I suspect that I’m being conservative in this assumption. By using that as the yardstick, I’m going to draw the analogy that health care has changed as much over the last 150 years, since 1860, as it will over the next 25 years to 2035. With that as my premise, let’s look back at health care 150 years ago.
The year 1860 saw the beginning of the American Civil War. Although opium and ether were known, they were rarely used in surgery, and almost never on the battleground, where surgery was performed by giving the patient a stick wrapped in leather for them to bite on while they sawed off his leg (hence the nickname ‘sawbones’). Sterile dressings were unknown, and wounds were allowed, or even encouraged, to suppurate. There were no antibiotics, no thoracic surgery, no germ theory of disease (that came in 1865 with the findings of Joseph Lister), and no knowledge of bacteria, let alone viruses. Darwin’s Origin of Species had just been published the year before, in 1859, but Gregor Mendel’s work on genetics would not be published until 1865, so there was no understanding of the mechanism of how our bodies worked, even though the theory of evolution required a mechanism not-then explained. Moreover, Mendel’s work was largely ignored for decades, until well into the 20th Century, and Darwin’s work is still considered controversial today – although hopefully not here.
Neither drugs, nor advertisements for drugs were regulated, and people could, and did, make fantastic claims for quack nostrums, many of which were actively harmful. In short, we look back at that era and think of it as a Dark Ages of medical practice.
Likewise, when the practitioners of 2035 look back at us today, they will shake their heads at our profound ignorance, and the dangerous things we do to patients. Let me use pharmaceuticals as an example. Although things are changing rapidly, the three traditional means of finding new drugs are still in widespread use: accidental discovery, as with penicillin; trial and error, as when pharmaceutical companies screen tens of thousands of compounds before selecting one for development; and studying compounds used by witch doctors and wise women, as with the discovery of digitalis. In 25 years, we will have a profoundly improved understanding of the mechanisms of the body, genetics, disease, and disfunction, and we will approach treatment and cures deliberately, almost as an engineering problem rather than a process of problematic scientific discovery.
Jump ahead 25 years
Now let’s jump ahead twenty-five years, to the beginning of 2035 and consider what it might be like, and then come back to the present to see how we might get there from here. Be warned, though, that I’m going to give you one possible scenario of the future, based on the evidence I see today, but I want to emphasize that the future will be different in many important respects. In particular, I would encourage you to consider two specific aspects about the future. First, I would encourage you to consider a future that is much more advanced than I’m proposing. My comments constitute, in effect, an educated guess, but if I’m wrong about the future of health care, it will be because I’m being too conservative, not too aggressive. And second, I find the political situation, both locally, in the United States and Canada, and globally, extraordinarily complex. Therefore I would suggest you should consider a complete series of background scenarios over the varieties of political changes possible over the next two-and-a-half decades. I don’t have time to do this today, so it is, as they say in the finest universities, left as an exercise for the reader
So, let’s assume that it is the beginning of a new year, 2035. What does health care look like? First, there will be a global computer network that gathers information about the health of each individual within the network, which covers almost two-thirds of humanity, to provide early warning signals about possible new diseases and epidemics. State and provincial departments and ministries of health accumulate information about the state of health of every one of their citizens instant-by-instant, strip off personal identifiers, and pass the information on to national computer agents.
These national computer agents, or health-bots, search for patterns that indicate the emergence of diseases, and assesses these patterns to determine if this is a new disease, a mutation of an existing disease, or the seasonal re-emergence of a known disease. As well, the national health-bots merge this information with a global health-bot network, operating out of the Center for Disease Control in Beijing, that looks for similar patterns on an international level. If a disease reaches a measured level of importance, particularly if it is a known virulent disease or a new disease, the health-bots notify the relevant national and international bodies, and provide all known information about the disease, including the relevant genetic markers of people who have caught or transmitted it.
From this information, humans, working with seemingly intelligent computer research assistants, begin inferring the genetic pattern of the disease from the genetic patterns of the individuals who have contracted the disease, while researchers are sent into the field to take direct samples from these infected individuals. These samples are collected within 48 hours of initial notification. From the inferences and the direct data, the gene sequencing of the disease is completed within another 24 hours, and the necessary vaccine or antibiotic countermeasure mapped out. Within a week, 1,000 doses of a test vaccine or antibiotic are available for testing on volunteers, who have already been identified for genetic suitability and contacted.
Within the next two weeks, the potential countermeasure has been administered by the volunteers’ health care practitioners, and their responses have been gauged. Based on the predictive models and how well they mirror the actual responses of the volunteers, the vaccine or drug is approved for general use, along with refined estimates of the total number of doses necessary to stop the potential epidemic. The doses are ordered, and within three additional weeks, the most important potential victims are given the countermeasure, and the potential epidemic is stopped before it truly gets started.
Monitoring health, heartbeat-by-heartbeat
The smallest unit, or building block, of this system is the embedded computer companion that most of the world’s population now uses, coupled with the widespread decoding of individual genomes. It now costs the equivalent of $100 to decode an individual genome, the vast majority of which is administrative cost. These computer companions monitor individual health heartbeat-by-heartbeat, and are able to detect problems early from heart rate, galvanic skin response, fluctuations in body temperature, subconscious minor muscle movements indicating discomfort, and other indicators. If appropriate, a computer companion will signal any significant abnormality to the individual, her health practitioner, and, if warranted, a local ambulance corps, as well as her state or provincial health-bot. Moreover, the global health-bot has tens of millions of patterns of health risks for every conceivable known health threat, including heart attacks and strokes, and makes these patterns available to individual computer companions. As a result, each computer companion has an almost uncanny ability to anticipate health threats and problems as they emerge – and this ability steadily improves as more and more data is collected, analyzed, and collated by the global health-bot network.
This detailed, individual monitoring of instantaneous health has led to a dramatic decrease in significant heart attacks, strokes, and other sudden-onslaught health threats, as well as the identification of early warning signs of health risks. It has also led to a graduated scale of health insurance premiums, based on the lifestyle factors that are matters of personal choice, like fitness and diet. Genetic factors are excluded by law in determining insurance premiums on the premise that no one is responsible for the genes handed to them by their parents.
Meanwhile, non-infectious diseases, like cancer and diabetes, have largely been cured, or are at least managed, and the survivability of all cancers, especially sneaky ones like ovarian and pancreatic cancers, that don’t present symptoms until very late, has risen dramatically. Not only are they detected much earlier, but they can be cured, often in a single treatment that amounts to a resetting or reprogramming of the individual’s genetic code that cancels out the cancer, diabetes, cystic fibrosis, multiple sclerosis, celiac, or other genetically-linked disease.
Treating aging like a disease
At the same time, there is serious research being done on treating aging like a disease. Not all of the problems have been solved yet, but enough has been done that there is a very real prospect that those who are in reasonable health in 2035 will be able to live as long as they choose – or until their money runs out, which isn’t quite the same thing. Organ, joint, and other body parts are routinely replaced from organs grown from the patient’s own stem cells, overcoming the problems of immune-system rejection. An obvious consequence of these developments is a dramatic increase in life expectancy to beyond 100 years. How far beyond, no one really knows, and accidents and suicide have become the two leading causes of death.
All these changes have not only revolutionized health care, but fostered a pitched battle over pension rights, entitlement to government-sponsored health care treatments, and intergenerational conflicts that were unknown in previous decades. In essence, these debates can be boiled down to a simple example: if it becomes possible for someone to live to age 120, for example, after working 40 years from age 25 to age 65, do they have the right to collect a pension without any further contributions to society for 55 years? If life expectancy extends beyond 120, how long are they entitled to be ‘retired,’ i.e., to contribute nothing except money? These are issues that have never had to be confronted before – but they have now reached a rolling boil. The most recent issue is whether it is ethical to restore reproductive rights and abilities to people of any (not ‘either’) sex who, in earlier days, would have been considered far too old to have children.
The future of the pharmaceutical industry
The pharmaceutical industry is still very much alive, but much changed. Not everything is known or understood about how or why diseases attack some humans, but not others. And while the human genome, and its interaction with the human proteome, is being intensively studied, the recursive nature of the subroutines embedded in the genome have turned out to be far more complex than anyone expected. Big pharmaceutical companies spend most of their research dollars outside their own companies, in networks of small, entrepreneurial companies. Big pharma companies in 2035 are primarily involved in data gathering and assessment, drug development, clinical testing, manufacturing, distribution, and sales – the things at which they excelled at the turn of the 21st century.
Drug purchases and health treatment prices are negotiated between the computers of the supplier, payer, patient, and practitioners, with humans being involved only if there are significant disagreements. Price negotiations are largely based on mathematical models of previous transactions that have been accepted by all involved.
In short, people of 2035 will look at what the practice of medicine in 2010 as unforgivably primitive. And if this sounds far-fetched, let me quote professor John H. Holland, of the University of Michigan, who recently commented that ‘By the mid-twenty-first century, much of medicine as it was practiced in the latter part of the twentieth century—for example, using surgery, chemotherapy, and radiation to treat cancer—will look as ineffective as the bloodletting of earlier centuries.’ Holland is a professor of psychology, electrical engineering, and computer science at the University of Michigan, and a pioneer in complex systems and nonlinear science
So, let’s just assume, for the moment, that I’m right in my scenario. How would we get to there from here? That’s the subject of my next blog.
© Copyright, Richard Worzel, February 2010.
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