Developed Countries

The Correct Prescription

...for healthcare systems under strain. For the developed world, Covid-19 was the starkest possible reminder that it was far from immune to communicable disease outbreaks.

In Mexico, 75% of adults are overweight or obese. Police officers in Mexico City join an exercise program to lose weight.Rodrigo Arangua/Getty Images

Despite the pandemic’s dev­as­tat­ing impact, the major long-term health chal­lenge remains the ever-grow­ing bur­den of non-com­mu­ni­ca­ble dis­eases (NCDs) – and a health­care sys­tem ill-equipped to cope with them. Peo­ple are liv­ing longer, which is good news. How­ev­er, they are liv­ing longer often with mul­ti­ple chron­ic con­di­tions. Mean­while, seden­tary lifestyles, obe­si­ty, poor diet and alco­hol and tobac­co use are lead­ing to increas­ing rates of “lifestyle-relat­ed” dis­eases such as heart dis­ease, hyper­ten­sion, can­cers and type 2 dia­betes.

Accord­ing to the World Health Orga­ni­za­tion (WHO), obe­si­ty is now at epi­dem­ic pro­por­tions, with around 2.8 mil­lion peo­ple a year dying as a result of being over­weight or obese. And this is no longer a prob­lem con­fined to the devel­oped world. As the economies of devel­op­ing coun­tries con­tin­ue to grow, so does the demand for West­ern-style food prod­ucts. World Bank fig­ures reveal that obe­si­ty-relat­ed dis­eases are now among the top three killers in most coun­tries and NCDs, in gen­er­al, are respon­si­ble for almost 70 per­cent of glob­al deaths.

A healthier diet could prevent between 20 and 24 percent of deaths a year.

SOURCE: EAT-LANCET COMMISSION

The tragedy is that many of these deaths are pre­ventable. This real­iza­tion is prompt­ing a reex­am­i­na­tion of some of the fun­da­men­tal notions behind health­care. Most health­care sys­tems were designed to inter­vene pri­mar­i­ly at the stage where the patient notices symp­toms and to offer “one size fits all” solu­tions. In terms of infec­tious dis­eases, as the find­ings of the FII‑I’s first health­care study revealed (see pages 44–49), the most effec­tive mea­sure coun­tries can take is to focus invest­ment on pre­ven­tion of pan­demics. Like­wise, in the case of NCDs, shift­ing from car­ing and cur­ing to pre­ven­tion and pre­dic­tive health­care can improve out­comes and reduce over­all costs.

SHIFT IN APPROACH

The biggest cause of mor­bid­i­ty in devel­oped coun­tries is NCDs. Yet NCDs are increas­ing­ly pre­ventable. Accord­ing to a study by Ramon Mar­tinez et al. (The Lancet, 2020), between 1990 and 2017 the num­ber of avertable NCD deaths increased glob­al­ly by almost 50 per­cent, from just over 23 mil­lion to more than 34 mil­lion. How­ev­er, many health­care sys­tems are based on a mod­el of react­ing to prob­lems rather than pre­ven­tion. But with the ris­ing bur­den of NCDs, this approach is prov­ing inad­e­quate. Health­care sys­tems in devel­oped coun­tries are strug­gling to deal with ever-grow­ing need and sub­stan­tial costs. Accord­ing to WHO, by 2017 health spend­ing in high-income coun­tries had reached almost $3,000 per capi­ta, stand­ing at just under 8 per­cent of GDP. There is lit­tle room for it to go high­er.

Pub­lic health experts have long argued for a fun­da­men­tal shift. “West­ern health sys­tems have been focused on deal­ing with the con­se­quences of poor diets and inac­tiv­i­ty, rather than spend­ing more of their efforts deal­ing with pre­ven­tion,” says Wal­ter Wil­lett, Pro­fes­sor of Epi­demi­ol­o­gy and Nutri­tion at Harvard’s T.H. Chan School of Pub­lic Health. “There are a few places that are mov­ing toward a dif­fer­ent mod­el, but the kind of sys­tem we have is real­ly irra­tional. And the train­ing of doc­tors still includes almost noth­ing on nutri­tion.”

UNEQUAL BURDEN

While more peo­ple are respond­ing to healthy eat­ing mes­sages, it still tends to be those with high­er lev­els of edu­ca­tion, just as the peo­ple buy­ing health­i­er prod­ucts tend to be in high­er income brack­ets. Poor diets, along with issues such as inad­e­quate hous­ing and high­er rates of smok­ing, mean there are sig­nif­i­cant gaps in life expectan­cy between rich and poor even with­in the same coun­tries. In Eng­land, for exam­ple, the life expectan­cy gap between the least and most deprived areas is almost ten years for men and eight for women.

In addi­tion, there is the vicious cir­cle cre­at­ed by NCDs and pover­ty. Stud­ies show that low income increas­es expo­sure to risk fac­tors that cause NCDs, such as unhealthy diets and insuf­fi­cient phys­i­cal activ­i­ty, while NCDs in turn con­tribute to pover­ty by reduc­ing house­hold income and increas­ing health­care costs.

The microgreens market is growing rapidly. Research is being carried out into their use as functional foods in diet-based disease prevention. Ollie Millington/Getty Images

As long as the cheap­est foods are among the unhealth­i­est – like starch and sug­ar – the dif­fi­cul­ty will be in get­ting more peo­ple to change their behav­ior. “That is a huge chal­lenge. The food indus­try makes mas­sive prof­its by sell­ing starch and sug­ar in thou­sands of dif­fer­ent ways,” says Wil­lett. “They spend bil­lions a year on mar­ket­ing just in the US. That cre­ates a huge chal­lenge for help­ing peo­ple eat a healthy diet.”

But if the indus­try can put huge resources into mak­ing prod­ucts like red meat and dairy prod­ucts afford­able, then a rebal­anc­ing of the sys­tem could eas­i­ly make things like fruits, veg­eta­bles and whole grains cheap­er instead. Con­sumer habits do change, as the fall in con­sump­tion of red meat in coun­tries such as the US shows, with two-thirds of Amer­i­can con­sumers say­ing they are now eat­ing less of at least one kind of meat.

Western health systems have been focused on dealing with the consequences of poor diets and inactivity.

Walter WilletWalter Willet
Professor of Epidemiology and Nutrition, T.H. Chan School of Public Health, Harvard

“It’s a del­i­cate bal­ance,” says Wil­lett. “We have evi­dence that we can make big changes. Some of it is due to edu­ca­tion and aware­ness, some of it is due to pric­ing, but to have the most effec­tive change it’s going to be some com­bi­na­tion of those.”

Younger gen­er­a­tions may well be eas­i­er to win over, with veg­an and “flex­i­tar­i­an” diets becom­ing more pop­u­lar amid grow­ing lev­els of con­cern about ani­mal wel­fare and the envi­ron­men­tal impact of the food indus­try. The Meat­less Mon­day move­ment, for exam­ple, now has ini­tia­tives in more than 40 coun­tries, and sec­tions of the food indus­try see huge oppor­tu­ni­ties in healthy eat­ing. “Some of the fastest growth in the food retail and restau­rant indus­try in recent years has been in the health­i­er sec­tor,” says Wil­lett. Accord­ing to the US Food Indus­try Asso­ci­a­tion, sales of plant­based meat alter­na­tives increased by over 19 per­cent in 2018 and account­ed for $878 mil­lion in sales.

Chang­ing habits could bring immense ben­e­fits, as was shown in the land­mark 2019 EAT-Lancet Com­mis­sion report, of which Wil­lett was a lead author. “We used three dif­fer­ent approach­es to cal­cu­late how much pre­ma­ture mor­tal­i­ty we might pre­vent if every­body shift­ed to a health­i­er diet, and we all came up with a sim­i­lar fig­ure – about 11 mil­lion deaths a year. That’s around 20 to 24 per­cent of the total num­ber of deaths. If you added in more phys­i­cal activ­i­ty, that would have a fur­ther reduc­tion. So there’s a huge poten­tial impact.”

THE POWER OF DATA

One coun­try always close to the top of the league table for life expectan­cy is Japan, and one of the key rea­sons is thought to be diet. The Japan­ese gov­ern­ment, like many oth­ers, issues healthy eat­ing guide­lines that rec­om­mend dai­ly serv­ings of foods such as grains, veg­eta­bles and fruit, along­side oth­er nutri­tion­al guid­ance. But there are oth­er rea­sons, too, why life expectan­cy in Japan is among the high­est in the world.

As can be expect­ed for a coun­try famous for its tech­no­log­i­cal advances, Japan is also uti­liz­ing tech­nol­o­gy to meet its health­care chal­lenges, for exam­ple by invest­ing in robots to pro­vide nurs­ing assis­tance and in wear­able robot­ic tech­nol­o­gy to help elder­ly patients remain inde­pen­dent and stay in their own homes. Many peo­ple also expect vir­tu­al real­i­ty (VR) to become an inte­gral part of the health­care land­scape, from edu­ca­tion and train­ing to reha­bil­i­ta­tion and men­tal health ser­vices.

Doubling what OECD countries invest in their information systems would deliver a threefold return, according to OECD research.

Tomo­hi­ro Kuro­da is a pro­fes­sor in the fac­ul­ty of med­ical infor­mat­ics at Kyoto Uni­ver­si­ty Hos­pi­tal. “There is a lot of poten­tial in these tech­nolo­gies. Dur­ing the Covid-19 pan­dem­ic, stu­dents could not come to the uni­ver­si­ty med­ical school so we intro­duced VR instead of anato­my train­ing,” he says. “It can’t replace every­thing, of course, but I think it will be a very pow­er­ful tool. You can use it to eval­u­ate the skill of a sur­geon before they embark on real clin­i­cal prac­tice, for exam­ple. Anoth­er suc­cess­ful appli­ca­tion is for the fam­i­lies of demen­tia patients. It can help fam­i­lies to under­stand what peo­ple are expe­ri­enc­ing.”

MASS DATA – INDIVIDUAL CARE

One of the most promis­ing areas in health­care is the use of big data to mon­i­tor the effec­tive­ness of pub­lic health ini­tia­tives, improve under­stand­ing of the links between behav­ior and health out­comes, or even com­pare DNA data and anonymized health records to study the links between gene vari­ants and dis­ease.

Japan is one of the coun­tries that is realign­ing its health sys­tem around the use of big data to help cre­ate more per­son­al­ized care and move away from a “one size fits all” approach. The coun­try recent­ly passed leg­is­la­tion to allow the anonymiz­ing of per­son­al health data for pub­lic use – data is col­lect­ed, anonymized and made avail­able to orga­ni­za­tions includ­ing in the pri­vate sec­tor, where it is used to inform the devel­op­ment of new treat­ments and drugs.

“The body that col­lects the infor­ma­tion col­lates it so you have a con­nect­ed his­to­ry of the per­son, and then anonymizes it for when it is pro­vid­ed to pri­vate sec­tor com­pa­nies, local gov­ern­ments or uni­ver­si­ty research cen­ters,” says Kuro­da. The infor­ma­tion comes not just from med­ical bod­ies, but any orga­ni­za­tions with health-relat­ed data. It is main­ly sent from hos­pi­tals, but local gov­ern­ments also hold data, for exam­ple from health check­ups.

Japan‘s Fugaku supercomputer, ranked as the world‘s fastest, is used for innovative drug discovery and to support personalized and preventive medicine.STR/Jiji Press/Getty Images

Coun­tries such as Fin­land and Esto­nia have led the way in using anonymized health data, with the lat­ter estab­lish­ing a vol­un­tary “gene bank” now cov­er­ing 5 per­cent of the pop­u­la­tion. But such ini­tia­tives are not free of con­tro­ver­sy. “The Japan­ese gov­ern­ment start­ed col­lect­ing insur­ance claim data from about ten years ago, but at the begin­ning access was restrict­ed,” says Kuroda’s col­league, Assis­tant Pro­fes­sor Gen­ta Kato. “How­ev­er, grad­u­al­ly they have changed their minds to accept pri­vate-sec­tor researchers.” The leg­is­la­tion is sub­ject to revi­sion every three years. Accep­tance of the pol­i­cy is high among Japan­ese cit­i­zens as they can see the poten­tial ben­e­fits. “Most of those com­ing into hos­pi­tal want their data to be used for med­ical advance­ment,” says Kuro­da. “Impor­tant­ly, peo­ple also have the right to opt-out, but in our expe­ri­ence less than 1 per­cent want to. This says quite a lot.”

Japan is home to the world’s oldest population, with 80,450 centenarians – a rise of 9,176 since 2019.

SOURCE: JAPANESE MINISTRY OF HEALTH AND WELFARE

What is cru­cial, how­ev­er, is that the data is con­sis­tent, well-orga­nized, detailed and uni­ver­sal, so it can be pooled with oth­er datasets to offer far greater insights than those avail­able from a sin­gle study. “This is what makes it pre­cious,” says Kato. “Oth­er coun­tries that want to use health­care data to improve their health­care need to make sure they gath­er it sys­tem­at­i­cal­ly and from uni­ver­sal cov­er­age – then lat­er gen­er­a­tions can enjoy the fruits.”

CHANGE OF DIRECTION

Many sec­tors have been trans­formed through new tech­nolo­gies, but the health­care sec­tor has gen­er­al­ly, for a num­ber of rea­sons, been rel­a­tive­ly slow. “We are late in imple­ment­ing some tech­nolo­gies because there are all sorts of reg­u­la­to­ry bar­ri­ers and issues around approval and reim­burse­ment,” says Claude Clé­ment, Pres­i­dent of BioAlps, an orga­ni­za­tion that works to sup­port and rep­re­sent the grow­ing clus­ter of life sci­ences com­pa­nies and insti­tu­tions in west­ern Switzer­land. “Also, peo­ple in the field of health are intrin­si­cal­ly con­ser­v­a­tive, espe­cial­ly doc­tors – the mind­set of the health indus­try is not nat­u­ral­ly adapt­ed to the chang­ing world.”

Clé­ment believes, how­ev­er, that there is enor­mous poten­tial. A good exam­ple is the field of neu­ro­science. “We are real­ly at the very begin­ning of try­ing to under­stand the brain and how it works,” he says. With aging pop­u­la­tions, Alzheimer’s, Parkinson’s and epilep­sy are more preva­lent than they were 50 years ago, yet while bil­lions have been invest­ed in seek­ing new drugs to tack­le these dis­eases, lit­tle has come of it. “We need to go anoth­er way,” says Clé­ment. “While in the past we main­ly relied on phar­ma, increas­ing­ly we are look­ing to med tech for solu­tions. That means look­ing at elec­tric­i­ty, light, ultra­sound.”

An attendee at Ceatec Japan 2019 wears 3D glasses to try out the new Orbeye surgical microscope system.Tomohiro Ohsumi/Getty Images

As well as ben­e­fit­ing patients, this shift could also help to ease the bur­den of health­care costs. “The cost of devel­op­ing drugs is enor­mous, some­times well over $1 bil­lion. In some spe­cial cas­es, like rare dis­eases, the price charged can reach $1 mil­lion a year for treat­ing a sin­gle patient. Should we devel­op such a drug, or should we focus on how to treat oth­er unmet med­ical needs that have a big impact on soci­ety? These are fun­da­men­tal ques­tions,” says Clé­ment. “We need to find bet­ter health­care solu­tions at a low­er cost. We need to redi­rect our efforts toward afford­able health­care that is avail­able more wide­ly.”

MAKING TECHNOLOGY MAKE A DIFFERENCE

Devel­op­ments in smart health or dig­i­tal health have wider impli­ca­tions. “Up to now we have always tried to keep health data pri­vate, between your doc­tor and you. Now we are try­ing to gath­er data to find trends and treat­ments using AI and big data. It is a col­lec­tive approach, instead of the pri­vate approach we have had in the past,” says Clé­ment. “But the results will be more treat­ments that are bet­ter tai­lored to indi­vid­ual needs. In the future, new data tech­nolo­gies will lead us to pur­sue per­son­al­ized med­i­cine, but this will only be pos­si­ble if we have first col­lect­ed a mass of infor­ma­tion. Dis­eases prop­a­gate every­where in the world. Covid-19 is a good exam­ple. There are no con­ti­nen­tal or nation­al bor­ders. So, we need to think in a dif­fer­ent way.” Some progress is being made in this direc­tion with glob­al ini­tia­tives work­ing to remove the obsta­cles to data shar­ing across bor­ders. Among them are the Inter­na­tion­al Rare Dis­eases Research Col­lab­o­ra­tion, the Glob­al Alliance for Genomics and Health, and Neu­ro­da­ta With­out Bor­ders. Research into the brain is one area where glob­al col­lab­o­ra­tion on shar­ing data and infra­struc­ture has great poten­tial.

Digital therapies support neurorehabilitation for stroke or Parkinson’s patients. Mindmaze, a Swiss company, enables patients to practice movements with their healthy side, while giving the brain the illusion that the paralyzed side is moving.Mindmaze

For Clé­ment, this new approach could bring huge ben­e­fits not just to patients in devel­oped coun­tries but around the world. “The approach we have today is very self­ish. You treat your­self, your own dis­ease, by going to your per­son­al doc­tor. Indi­vid­ual treat­ment like this is reserved for rich coun­tries. But dis­ease does not only affect the wealthy,” he says. “We should focus on what the pop­u­la­tion needs. If our tech­no­log­i­cal dreams are not in line with this, we should not devel­op them.”

CALL TO IMPACT
1 Food companies should put more effort into encouraging consumers to eat fruit, vegetables and whole grains, for example by making these more affordable. 2 Governments must find ways to alleviate privacy concerns around the collection of mass data as this will enable the development of more personalized treatments. 3 New technologies should be used to develop affordable healthcare that is widely available, not to develop solutions that are only accessible to those who can afford them.
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