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.
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.
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.”
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.
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.
“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.
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.
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.”
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.
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.”