To solve any task of control, the first question to be addressed is: WHAT IS GOING ON in the controlled system?
This section is a piece of analytics that can be entitled “What is going on in medicine: an autopsy report”. The subject of analysis is the situation and trends in medicine at a global level; that’s why the focus is on so-called “developed economies”, primarily USA. Why USA? There are several reasons to choose USA for analysis:
(1) This is the center of today’s “western” civilization which is as yet setting the rules of the game and technology standards for the whole world;
(2) USA did not experience the horror of two world wars, so its economy, including healthcare, had an opportunity to develop without restraints, and all demographic indices were not affected by devastating blows;
(3) USA features the highest national healthcare expenditures; this allows an estimate of what medicine can achieve under the best possible financing;
(4) Thanks to generous financing of medical research, the situation in the US healthcare is described in maximum detail.
The situation in the Russian healthcare will be analyzed in a separate article.
Those who would like to jump to key message of this report can press here.
- What are the problems and unmet needs of medicine?
- What is the real progress in medicine over the recent 50-100 years?
- What are the realistic prospects of the “most promising medical technologies of the 21st century”?
- What are the obstacles for progress in medicine?
- What route should medicine take in the 21st century, considering the social, economic, scientific and technological context?
I’m trying to adapt the text for a ‘qualified user’ – a person with common sense but free from numerous professional stereotypes. I’m not avoiding very arguable statements and digressions outside the medical mainstream.
I recommend to follow the sequence of questions, otherwise you run a risk of losing the line of logic.
We’ll start with one of the key questions: “What and who is medicine and broader – healthcare – designed for?” Interestingly, the real answer is not so obvious. By definition given by the WHO (the World Health Organization),
Health system: (i) all the activities whose primary purpose is to promote, restore and/or maintain health; (ii) the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.
Now let’s look at the definition of medicine (Russian version): “the system of scientific knowledge and practical measures designed to serve detection, treatment and prevention of diseases, preservation and improvement of health and productivity, and life prolongation”. The English version reads: «is the science and practice of the diagnosis, treatment, and prevention of disease”. By definition, medicine is the cornerstone of the Healthcare (Health system).
Take home message: medicine as a part of healthcare is designed to restore and maintain good health.
Since we have mentioned health, take a look at the WHO definition: health is «a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity».
An important point that most general practitioners don’t remember: talking about health, the WHO experts refer not only to the physical body, but also to mental phenomena (attributed to psyche, or soul in plain language), and even the society in general. Why is the definition of health so broad? The answer is simple: because the human is not limited to the physical body. We also have the soul (studied more closely by PSYCHO-logists) and something else that connects us with the human society in general. To put it shortly, health means well-being at all the three levels of human existence: physical, psychical (mental), and social. Let’s memorize this very important point.
Now let’s come back to the first question: “Who and why needs medicine?” (“What and who is medicine designed for?”) To answer it, we’ll have to figure out the following: Who takes part in healthcare?
Some participants are obvious: common people, patients (they are the major ‘consumers’); doctors and other health professionals (those who make their living by taking care of others’ health); governmental structures (they regulate health care, provide infrastructure, etc.). Is that all? Certainly not, the most interesting part is just starting. Not that outstanding at the first glance but key players in healthcare are: pharmaceutical companies, manufacturers of medical equipment and supplies, distributors (vendors) of drugs and medical equipment, insurance companies. The last list includes those who are not only involved in the process but also receive profit from it. These players have an alternative answer to the question “what is medicine designed for?”: “Medicine is the source of profit”.
Now as we have briefly discussed what medicine is and what it is designed for, let’s proceed to the needs and unsolved problems of medicine. Each of the participants has certainly his own needs and problems.
Let’s briefly look into unsolved needs of patients – those who medicine is designed for. For simplicity we’ll limit ourselves to medical problems in narrow sense. First of all, these are chronic diseases that reduce lifetime, cause disability, and worsen life quality. Here are ten most prevalent diseases of aged residents of the USA: arterial hypertension, senile dementia (including Alzheimer’s disease), coronary heart disease, depression, osteoarthritis, osteoporosis, diabetes, chronic lung diseases, cancer, stroke and its consequences. And here is the list of most important causes of death and disability in the world: cardiovascular diseases (coronary heart disease, stroke), cancers, chronic lung diseases (including bronchial asthma), diabetes, mental diseases (depression, addiction, dementia), diseases of bones and joints (osteoarthritis, osteoporosis), impaired vision and hearing. The listed diseases take the lion’s share (>90%) of all healthcare expenses in most countries. According to the experts, up to 80% of all chronic diseases can be prevented by healthy life style – can be, but are not prevented. It is also commonly recognized that social and psychological factors (chronic stress in the first place) play a leading role in the onset on chronic diseases.
The problem of end consumers can actually be divided in two:
(1) limited access to medical help, which is common not only in low income countries but also in many EU states and USA;
(2) low efficiency of medical help.
Even by formal criteria, medications used in most prevalent chronic disease fail to help from 38% of patients (antidepressants) up to 75% of patients (anti-cancer treatments) (Brian B.Spear, Margo Heath-Chiozzi, Jeffrey Huff, «Clinial Trends in Molecular Medicine», vol.7, issue 5, 1 May 2001, pp.201-204, cited by: The Case for Personalized Medicine, 3rd Edition, p.7).
At the bottom line, the patients as the end consumers of medicine have the following unsolved problems:
(1) there’s no opportunity to prevent chronic diseases (nothing favours individual efforts, methods of prevention are not taught widely);
(2) if you get ill, access to medical help is limited due to various reasons, mostly financial;
(3) if you can access doctors, this is of little help: you’ll have to take ineffective and costly medications for the rest of your life.
Now let’s take a look at the problems of another key player – the state. Regardless of the financing mechanisms in the healthcare system (private insurance, national health service or intermediate forms), the government faces certain systemic (regulatory etc.) and infrastructure issues, since poor health of residents translates into social tension, poor tax proceeds, etc.
Our analysis is based on an extensive expert report from the EU: A report from the Economist Intelligence Unit «The future of healthcare in Europe«. Here are the major problems mentioned in the report to reflect the government’s viewpoint:
- Ageing populations and the related rise in chronic disease (importantly, the direct healthcare costs are much lower than economy losses from disabilities);
- Costly technological advances;
- Patient demand driven by increased knowledge of options and by less healthy lifestyles;
- Legacy priorities and financing structures that are ill-suited to today’s requirements (that is, the structure designed to manage acute diseases is poorly suited to treat today’s most important diseases like cancer, arterial hypertension, mental diseases, heart and lung diseases, diabetes, stroke, etc.).
According to the authors of another expert review, in USA alone the annual expenses for unnecessary or incorrectly prescribed medications or procedures amount to about $210 billion; in addition, $300 to 490 billion are spent to treat preventable diseases.
The problems in medicine from the viewpoint of doctors and other healthcare professionals depend a lot on the particular person (age, speciality, professional level, world outlook, etc.). However, I’d take a risk and formulate major trends present in “mainstream” medicine both in Russia and worldwide, especially in developed economies:
1) More than half (up to 80%) of their working time doctors spend on administrative and paper work;
2) Almost everything doctors do is tightly regulated by standards of diagnosing and treatment established for a particular disease (diagnosis);
3) If a patient has certain complaints but has no diagnosis, hardly any ‘mainstream’ doctor will be able to help him/her;
4) After 10-15 years of practice, the doctor usually reaches upper limit of professional growth when all available treatment methods have been mastered; after that, the work turns into routine lacking any creativity;
5) The interaction between doctor and patient implies that doctor’s income depends on the amount of provided services, not on the patient’s health – that is, doctors are actually not interested in making their patients healthy. Life styles of many doctors are very far from healthy.
A separate issue in medicine is scientific research. As long as 10 years ago a very thorough and gloomy review stated that most published medical research give biased results. The reasons are: too small sample size, too small effect size or statistical power, incorrectly chosen treatment method or tested relationships (Ioannidis, John PA. «Why most published research findings are false.» PLoS medicine 2.8 (2005): e124.).
Another issue of both medical and legal nature is very high rate of adverse effects. According to 1998 data, in the USA mortality from side effects of medications prescribed only in hospitals amounted to 106 thousand cases. Overall mortality from iatrogenic causes (related to incorrect doctor’s manipulations or diagnostic procedures) in 2001 in USA alone exceeded 750 thousand. This put iatrogenic causes of mortality in USA at the top of all other causes. For reference: mortality from cardiovascular diseases amounted to 700 thousand, from cancers – to 550 thousand cases (source).
We have briefly reviewed unsolved problems in medicine from the viewpoint of patients, state and doctors. Now it’s turn of the beneficiaries – those who consider medicine as the source of profit. For reference: the sales of 12 largest pharmaceutical companies in 2013 exceeded $ 500 billion.
Looking into the problems that they see for themselves in today’s medicine we’ll refer to a report of a renowned audit company.
The pharmaceutical business sees the following three main problems:
1) Patients (especially in mature markets) have higher expectations than ever before. That is, new products should be better than old ones, and the price increase should be at least proportionate to benefit increase;
2) Low R&D (research & development) productivity. That is, the number of new approved products is not rising despite huge R&D expenditures;
3) Corporate culture that is based on outdated strategies and management styles. A particular issue is lack of innovation and coordination between different divisions within one company.
Other factors that pharma business considers as important for its development are: financial and debt crisis, globalization, pressure of demographic and epidemiological trends (ageing population and related increase in chronic diseases), new communication technologies, and healthcare reforms.
Thus, quite predictably, the focus of pharma companies is everything that might affect their profits. The needs and problems of patients and governments are only examined in the light of potential threats or opportunities for profits.
Now let’s sum up this section focused on needs and unsolved problems of medicine.
1) Medicine as a part of healthcare is designed to restore and maintain health – physical, mental and social well-being of humans.
2) There are four major players taking part in healthcare activities: patients, governments, doctors and manufacturers/vendors of diagnostic and treatment tools (named here for convenience as ‘pharma companies’).
3) The interests of patients and governments are generally in line with the goals of medicine. However, the interests of doctors and pharma companies, curiously enough, run counter to the goals of medicine. Pharma companies are interested in growing or stable profits, while this is only possible if patients have more diseases, ‘desirably’ chronic diseases. Doctors’ incomes are in direct relation with the number of “treated patients”, thus healthier population would mean lower income.
4) Visual and obvious problems of medicine are growing prevalence of chronic diseases, lack of effective prevention, insufficient access to medical help (mostly due to financial reasons), and low efficiency of this help.
5) The UNDERLYING problem of medicine is the CONFLICT OF INTERESTS of the key players of healthcare (doctors, pharma companies) who have private or corporate interests contradictory to the objectives of healthcare.
Quite simple and transparent logic has led us to disappointing conclusions. However, they don’t seem to be a mistake. Well-reasoned disproof is welcome.
In the above discussion of the unsolved problems of today’s medicine we have found the following. The end consumers of medicine, patients, lack effective prevention of the most prevalent chronic diseases; they have limited access to medical care; the available care is not effective enough, and may even be dangerous. From the viewpoint of governments and other payers, too much is spent on unnecessary or wrongly prescribed medications or procedures; technological advances (including development of new medicines) are too costly. The underlying problem is the conflict between the interests of key players of healthcare (which is profit) and the objectives of the healthcare itself.
What did the situation look like 100 years ago? What problems did medicine face then? How were those problems managed?
A relevant measure of unsolved problems for patients and society is the causes of mortality. To make it simple, let’s look the data available for USA – the country considered as the “reference” of progress in medicine.
|1. Cardiovascular diseases||1. Cardiovascular diseases||1. Cardiovascular diseases|
|2. Influenza and pneumonia||2. Cancers||2. Cancers|
|3. Tuberculosis||3. Accidents||3. Chronic respiratory diseases|
|4. Gastrointestinal infections||4. Diseases of early infancy||4. Accidents|
|5. Accidents||5. Influenza and pneumonia||5. Influenza and pneumonia|
Bearing in mind the absolute figures (see the references), the obvious conclusion is the following: the dramatic fall in mortality from 1900 to 1950 took place owing to almost 10-fold decrease in deaths due to tuberculosis, almost 7-fold decrease in deaths due to influenza and pneumonia, and multifold decrease in deaths due to gastrointestinal infections.
What was the cause of such an improvement? What was the role of healthcare financing? What was the role of antibiotics and vaccines? All these questions were addressed in a detailed review published in 1977.
First, let’s look at the cause-effect relationship between healthcare financing and mortality.
A sharp increase in national healthcare expenditures in the USA in mid-1950s took place AFTER mortality had already dropped (see the diagram from the cited review of 1977).
Now let’s look at the role that vaccines and chemotherapeutics played in mortality reduction.
The cause-effect relations are easily seen from diagrams depicting the drop of mortality from a particular infection with time and the moment when a medical intervention for that infection was introduced.
The figures are self-explanatory: by the moment the medication or vaccine was introduced, the mortality had already dropped.
What does that mean?
Out of ALL vaccines and therapeutics introduced into practice in the 1930-60s (for scarlet ever, typhoid, measles, tuberculosis, influenza, whooping cough, pneumonia, diphtheria, and poliomyelitis) only polio vaccine MIGHT have had some influence on mortality from these infections.
The idea that the drop in mortality was caused by social reforms and improved social well-being, not by “laboratory medicine” was first published as early as in the 1950s. However, already in the 1970s such a position became “heretic”.
Today’s prevailing official opinion imposed on the public (like the one expressed here) ignores facts and common sense; it insists on the decisive role of vaccines and chemotherapeutics in the “victory over lethal infections”.
To sum up, there is strong scientific evidence for the following conclusions:
1) reduction of mortality in the USA (same is true for the UK) in the first half of the 20th century was due to infectious diseases;
2) the severity of respiratory infections reduced due to improved nutrition;
3) the severity of gastrointestinal infections reduced due to sanitary measures (water purification, food processing – for example, mild pasteurization, etc.).
Therefore, as early as in the 1950s it was shown that almost 2-fold decrease in mortality seen in countries like USA over the first half of the 20th century was caused not by new medications or vaccines but by improved social wellness and wide introduction of sanitation and hygiene. Contemporary research supports this statement (reference 1, reference 2).
An important point in maintaining the “outstanding role” of medicine in health improvement is that it justifies today’s tremendous expenditures in healthcare.
Had the role of “laboratory medicine” in fighting infections of early 20th century been refuted, today’s authority of pharmaceutical companies, as well as cost effectiveness of healthcare costs would have been under serious doubt.
Now let’s come back to the prevailing opinion about medical progress.
Here are results of a survey performed by British Medical Journal (BMJ) in 2007. The readers were asked to choose the most important out of the list of the greatest medical advancements since 1840 to present. The “short list” was prepared by the journal’s medical experts.
The final list of advancements with comments is given below (cited from http://jonbarron.org/article/worlds-greatest-medical-advancements):
|1. Introduction of sanitation and hygiene (late 19th century)||This is a definite and objective advancement – socio-economic, but not medical.|
|2. Discovery of antibiotics (1928)||The role of antibiotics in reduction of mortality from tuberculosis, pneumonia, typhoid and scarlet fever is questioned by some authors.
Excessive use of antibiotics caused emergence of dangerous bacterial strains resistant to any treatment – that is, the utility of this discovery has now devalued, and the WHO documents support this opinion.
Uncontrolled use of antibiotics in children threatens chronic diseases later in life (reference)
|3. Discovery of general anesthesia (mid-19th century)||Opiates and other herbal remedies were used as anesthetics in Ancient Rome, while anesthesia with acupuncture was known in Ancient China|
|4. Introduction of vaccines (early 19th century)||There are sound reasons to challenge the efficacy and safety of vaccines; several studies cover this issue (for example, reference 1, reference 2)|
|5. Discovery of DNA structure (1950s)||“Human genome” project (end of the 20th century) revealed a much less significant role that genes play in diseases than it had been believed in the middle of the 20th century. Absence of direct links was proven between gene and feature, gene and disease, and even gene and a particular protein.
This discovery has not translated yet into cardinal solutions for the problems of today’s medicine – most importantly, in the treatment of chronic diseases.
|6. Microbial theory of diseases (end of the 19th century, Pasteur)||This forms the basis for “advancements” ##1 and 2. Today it needs a revision. In particular, discovery and research into innate immunity (1990-2000s) pointed at individual host reactivity as the major factor of infection severity.|
|7. Oral contraceptives (1960s)||Later on they were found to cause numerous side effects, including hormone-dependent cancers|
|8. Evidence Based Medicine (EBM)||EBM principles proposed in the 1990s have actually failed in real life practice, as suggested by several extensive reviews: for example, of 2005, 2011, and 2014. The reasons include: pharma companies’ conflict of interests, methodological inconsistency, replacement of clinical thinking by rigid standards. As the result, less than 30% of currently used treatments meet the requirements of EBM (data for hospital medical care in the USA). That is, 70% of patients are treated by a method without proven efficacy and safety – and this takes place even in hospitals, even in the USA. One can only imagine what happens in outpatient setting.
More importantly, proof of efficacy in line with EBM standards IS NOT A WARRANTY that the medication will help the given patient.
(X-ray, computed tomography, magnetic resonance imaging)
|These methods developed owing to progress rather in other fields of science and technology, than in medicine.|
|10. Computers||Their use in medicine is a result of progress in other fields|
|11. Stem cells||A technology that still holds more promise than real results|
|12. Surgery in traumatology||This is a true advancement. The major progress in this field was due to field surgery and treatment of car accidents.|
|13. Prosthetics and transplantation||This is a true advancement. Importantly, the need in such interventions is most often the result of ineffective conservative (i.e. drug) treatment.|
|14. Subcellular methods (gene therapy, metabolomics, metagenomics)||Still more a promise than a reality. Potentially a promising approach to early diagnostics. Metagenomics is the study of bacteria living inside the body and affecting the onset and natural course of many diseases.|
What conclusions can be drawn from this table?
The real progress in medicine over the last century is mostly progress in SURGERY and introduction of breakthroughs made in OTHER FIELDS OF SCIENCE.
All the claimed advancements in pharmacology (pharmaceutical business) are in reality quite insignificant. Pharmacology has failed in reducing the burden of most highy prevalent chronic diseases.
These conclusions are supported by statistics on the efficacy of medications for certain most important chronic diseases (from antidepressants useless in 38% of cases to anticancer drugs useless in 75% of cases) (Brian B.Spear, Margo Heath-Chiozzi, Jeffrey Huff, «Clinial Trends in Molecular Medicine», vol.7, issue 5, 1 May 2001, pp.201-204, cited from: The Case for Personalized Medicine, 3rd Edition, p.7).
Back in 2003, Allen Roses, worldwide vice-president of genetics at GlaxoSmithKline (GSK) admitted that most prescription medicines do not work on most people who take them
He literally said the following: «The vast majority of drugs — more than 90 per cent — only work in 30 or 50 per cent of the people. I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.»
Here are proportions of patients who benefit from medications approved for specific illnesses (from the cited interview):
Drug efficacy rate, %
|Hepatitis C (HCV)||47|
Many doctors may consider these figures as a normal situation, putting this fact as a ‘systemic limitation’ of medicine that cannot be overcome.
However, since today’s medicine isn’t different from any business, one can look at drug’s efficacy as the efficacy of a business process or a service. Then such a failure to help a major part of patients translates into something ridiculous. Imagine you board a plane to get to some city and in 50% of cases in brings you to a different place or crashes. Imagine you buy a car and in 50% of cases it fails to start. You buy a washing machine and in 50% of cases it leaves your clothes dirty. Is that OK? The answer is obvious.
As long as the interest of the major healthcare stakeholders setting the rules of the game is PROFIT, the patients should have the right to request that they pay for the RESULT of the service. However, a more adequate solution seems to be removing profit from medicine, since profit is an inevitable source of the conflict of interests and hence the source of all other problems in medicine.
Now, as we have reviewed ‘medical advancements’ of the 20th century, let’s say a few words about the obvious failures. These are the following: inability of today’s pharmacology to manage the major chronic diseases and causes of mortality: cardiovascular diseases, cancers and diabetes.
There are doubtless successes in instrumented diagnosing and surgical treatment seen in oncology, cardiac surgery and other fields. But these successes are not due to pharma companies that shape ideology of today’s medicine. As for conservative (non-surgical) treatment of cancers, diabetes, coronary heart disease, arterial hypertension (you can check the current state of affairs in the corresponding areas by clicking the links) – which are the major causes of disability and mortality – medicine has failed to solve the consumers’ problems, and in particular to create 1) effective, 2) safe and 3) affordable means of treatment and prevention.
The list of obvious failure of the medicine of the 20th century also includes its contribution to mortality. The most extensive analysis is available for the 2001, USA. Part of Table 1 from this review is given below: annual mortality from iatrogenic causes (i.e. causes related to wrong/ inadequate treatment care or diagnostic procedure).
Table. Estimated annual mortality from iatrogenic causes (USA, 2001)
Number of deaths
|Adverse drug reactions in hospitalized patients||106000|
|Malnutrition (in nursing homes and similar institutions)||108800|
|Adverse drug reactions in outpatients||199000|
For comparison: mortality from cardiovascular diseases in 2001 in USA amounted to about 700 thousand, from cancers – to about 553 thousand. That is, in USA, “the country of the best medicine”, iatrogenic factors has become the major cause of mortality. The situation has hardly changed a lot since 2001.
In the EU, annual mortality from adverse drug reactions (ADRs) is estimated at 197 thousand; ADR is the fifth most common cause of hospital death; ADRs account for 5% of all hospital admissions; and cost the society €79 billion (source).
Now let’s come back to chronic diseases. A standard goal of pharmacotherapy of chronic conditions is “control” over particular physiological endpoints: blood pressure, blood sugar, “bad” cholesterol, etc.
Why isn’t it possible to shift from mechanistic influence on separate signs or complications to the influence on the underlying causes of these conditions? There is no simple answer to this question.
Most chronic conditions have multiple contributing factors. But at the level of the whole individual the situation most often can be formulated as the following: diseases are caused by wrong way of life (this is not quite the same as what is called “unhealthy lifestyle”), by chronic stresses and failure to either manage the stresses or correct the way of life.
What does “the wrong way of life” mean? What is the “right way”? These and many other questions belong to the field that today’s medicine doesn’t look into and is not going to. Medicine reduces a human to the body and considers the issues of soul (psyche) to be the subject of psychologists and quacks. The issue of the purposes of life, fundamental to define the right ways of life, is put outside the framework of science.
Meanwhile, by the WHO definition, health is «a state of complete physical, mental (psychical), and social well-being and not merely the absence of disease or infirmity». As long as medicine reduces humans to their physical bodies, such a medicine has no chances to solve the problems of health.
Why am I coming back over and over to this discrepancy between the declared objectives of medicine and its real life “working ideology” and everyday tools? Why is this so important? Because over the last 50-60 years medicine has been growing less and less cost effective. The cost of developing each new therapeutic exceeds $ 2 billion.
As the result, all these costs are put as a burden on the end consumers and the society. If the benefit that the end consumer gets from the new medication (in terms of improved life quality, prevented disabilities, longer lives) is minimal, then the following question is relevant: maybe THE MODEL should be changed that all new drugs and medical technologies are based on?
With this rhetoric question we are closing this part of “autopsy report” looking forward to the “most promising trends” in medicine. They will be the focus of the next section.
Summary and conclusions:
- The significant drop in mortality seen in developed economies over the 20th century (as exemplified by the USA) was rather due to improvement in social wealth (better nutrition, housing, etc.) and wide introduction of sanitation and hygiene than to development of new medical technologies like new drugs and vaccines. This is very much in line with today’s official position of the WHO on the determinants of human health.
- The steep rise of health care expenditures in the second half of the 20th century (as exemplified by the USA) had only minor influence on the objective indices of public health.
- The role of vaccination and antibiotics in reduction of mortality from infectious diseases is not supported by facts.
- Out of all medical breakthroughs of the 20th century only two survive critical review: progress in surgery and introduction of technologies from other branches of science.
- Despite the huge investment in development of new drugs, over the last 50 years pharmacology has failed in relieving the burden of chronic diseases.
- Drugs, the major instrument of today’s medicine, remain ineffective, unsafe and expensive. Most of them, >90%, work in only 30-50% of patients. They don’t treat chronic diseases but only temporarily relieve certain symptoms.
- In developed economies iatrogenic factors (related to wrong medical interventions) are among major causes of mortality.
Thus, over the last 30-50 years medicine has been demonstrating very poor cost effectiveness: increasing investments are giving smaller returns in the form of benefit for health.
Question # 3. What are the real perspectives of “the most promising” trends in “the medicine of the 21st century”?
Mid-term forecasts for medicine: critical analysis of different viewpoints
The term “promising” in this context should mean “being able to solve problems” – the unsolved problems of major players in healthcare. I’d like to remind the reader that healthcare consumers – patients and the society – have three major problems with available solutions:
1) they are too expensive;
2) they are ineffective (fail to solve the problem);
3) they are unsafe.
There are viewpoints about the future expressed by various groups of healthcare stakeholders; most often these viewpoints are translated by
1) experts representing the state or other ‘payers’, and
2) experts representing the business community – companies developing new drugs, new instruments for diagnostics and treatment, and new technologies.
Unfortunately, the opinions of patients are very rarely surveyed. Meanwhile, patients do have their position, and it translates into preferences of certain methods and approaches which sometimes puzzle and annoy medical professionals. Luckily, those actual preferences of a major part of patients are sometimes reflected in some strategic documents of the World Health Organization: see WHO paper on alternative treatments. According to this document, more than 100 mln of Europeans use alternative methods of treatment. Much more people use them in other regions. This doesn’t mean alternative medicine is definitely better: at least, it is considered more affordable and safe.
The most enthusiastic prophets of “the medicine of the future” are journalists who regularly issue their lists of “top trends in medicine of the 21st century”. Let’s take as example one of them published in a Russian magazine. As most journalists, the author is not aware of the somber analytics on the efficiency, costs and safety cited earlier in this text. Nevertheless, the author insists on personalized approach to each patient and use of huge ‘objective data’. This particular article suggests “seven major trends of the 21st century medicine” that we comment below.
Table. “Top trends in medicine of the 21st century”
|1. Genetic treatment of earlier incurable diseases with “viruses innocuous for human”||Most human diseases and about 100% of the most prevalent diseases have multiple risk factors and are inherited in a polygenic way (i.e. depend on many genes); the course of these diseases depends much on behavior and life style. That is, by definition this approach suits a small number of very rare diseases. The use of viruses as genetic vectors is potentially very dangerous since virus behavior is poorly predictable. And the issue of cost remains open.|
|2. Early diagnostics (“diagnostics instead of treatment”)||This approach is relevant and cost effective for life threatening diseases where effective and safe treatments are available. The mentioned combination of conditions (dangerous disease with effective and safe treatment available) reduces to zero the list of diseases that this trend suits. The most important chronic disease are not in this list.|
|3. Personalized drugs||This trend fails to take into account today’s huge drug development costs (> $ 1 billion) and multi-factor nature of most diseases.
However, individualized treatment already exists as a routine in all so-called ‘holistic’ methods that consider human as an integrity of at least physical body and mind.
|4. “Medical crowd-funding”||This is a good idea, but not quite about medicine. It also raises doubts in view of very high costs of developing new treatment methods in the ‘mainstream’ medicine. Also, people with chronic diseases usually make ends meet themselves.|
|5. Increased role of information technologies and access to ‘big data’||The author forgets about the major role of psychosomatic factors in the onset and course of most chronic diseases. These factors are very poorly assessed by the ‘mainstream’ medicine, but without them physiological parameters alone are not enough. Also, diagnostics cannot replace the lack of effective treatment tools.|
|6. “Medicine as a life style”||Fitness centers, spa and beauty salons and organic food shops – all these businesses built around health will hardly replace the need in a holistic system of consistent measures designed to prevent and treat chronic diseases|
|7. The duty of supporting and recovery of patient’s health will be put on the patient him/herself||This approach is essentially very reasonable: a person educated how to prevent and treat his/her own diseases will need professional help on very rare occasions.
However, today’s “medicine of repair” has very few preconditions for that. Even most doctors have very vague concept of what is health and how to support it.
The mainstream medicine doesn’t teach the doctor to consider patients integrally, to examine not only their physical but also mental and spiritual determinants of health.
And here is a forecast of the Institute for Global Futures about The Top Ten Health Care Trends for the 21st Century:
- Most hospitals, clinics, trauma centers, physicians, and patients will be connected to one large network enabling access to critical medical information.
- Consumer health information, accessible over a variety of Net channels, will become the most in-demand content worldwide.
- The medical industry will face an ethical and social dilemma over the disclosure of patient information.
- Health-care professionals, available via remote Internet connections, will provide services to millions of people who were previously under-served.
- Medicalbots, nonhuman intelligence agents, will dispense medical care to patients and doctors worldwide to save money and share expertise.
- Advanced nano-biology and genetic technology will eliminate many diseases, accelerate healing, and increase longevity.
- Bio-engineered food will help promote health and longevity.
- A new generation of smart drugs, implants, and medical devices will enhance our health and performance.
- Virtual-reality medical simulations will become the dominant mode of medical training.
- Cyber-health care that is customized for us – designed to monitor, diagnose, educate, and intervene regardless of location or time – will be common.
Predictions 1-4 are based on the progress in information technologies and are thus quite realistic. As to points 5-8 and 10, they rely on invention of new medical technologies or progress in the existing ones – technologies targeting the body. As already discussed above, human cannot be reduced to physical body, like health cannot be reduced to normal physiological parameters. That’s why these predictions are nothing more than illusions; they fail to take into account the problems of the existing technologies and trends in medicine over the last 50 years. Point 9, medical training: this part of the forecast has nothing to do with vital problems of healthcare. One thing is for sure: a student cannot become a doctor without seeing real patients.
After the enthusiastic journalist opus and futuristic illusions, we are coming back to the somber humdrum of life outlined in the Report from the Economist Intelligence Unit «The future of healthcare in Europe«.
Just to remind the reader, this document points as the following major problems of healthcare from the governments’ view:
1) mismatch of medicine’s organizational structure and today’s needs (prevalence of chronic over acute diseases);
2) costly technological advances;
3) patient demand driven by increased knowledge of options and by less healthy lifestyles: both patients and doctors are used to look for a “quick fix” instead of preventing the disease in the long term.
The future of healthcare will be shaped by seven separate, but interconnected, trends.
- Healthcare spending will continue to rise
- The structure of healthcare will be changing, as public resources fall short of demand.
- General physicians will become more important as gatekeepers and co-ordinators of treatment
- More effective preventive measures and fundamental lifestyle changes will be promoted
- European governments will need to find a way to improve collection and transparency of health data in order to prioritise investment decisions (it is admitted that the governments are not aware of the efficiency of the current investments).
- Patients will need to take more responsibility for their own health, treatment and care.
- Governments will have to tackle bureaucracy and liberalise rules that restrict the roles of healthcare professionals and artificially raise the cost of medical research.
One can easily see that the only trend shared with the previous «optimistic» list is higher significance of prevention. Nothing is said about particular new medical technologies – most likely because none of them meets the expectations.
The experts consider five extreme scenarios for European healthcare in 2030, depending on technological advances and direction of reforms. The authors admit that the difficulties of current debates are due to the fact that each stakeholder (such as insurance companies, doctors, and governmental bureaucracy) pulls the blanket on himself not caring about the patients’ interests.
Here are those five scenarios for 2030:
|1. Technology triumphs and cures chronic disease, while e-health takes a prominent role in the management of healthcare||The most optimistic and that’s why least realistic scenario. To become reality, it needs: 1) outstanding successes of new technologies and drugs; 2) sufficient financing; 3) political and economic stability; 4) coordinated efforts of all stakeholders working for common benefit.
Today each of the listed factors lacks its preconditions, let alone all conditions for all the factors. Besides that, the scenario relies too much on technologies and disregards the role of prevention and other systemic solutions needed for chronic diseases.
|2. European nations join forces to create a single pan-European healthcare system||The scenario implies partial surrender of sovereignty in healthcare, cuts in the number of hospitals and medical staff, and considerably reduced role of general practitioners – all this for the sake of standardized care and optimized costs.|
|3. Preventive medicine takes precedence over treating the sick||A major hurdle for this scenario is conflict of interests in doctors, biomedical scientists (they can expect reduced financing) and businesses related to unhealthy lifestyles. A significant shift in world view, attitudes and priorities in many people and social groups will be necessary, along with great political will at the level of national governments.
Positive results will be much postponed; people with chronic diseases may become stigmatized.
|4. European healthcare systems focus on vulnerable members of society||The idea of social equity and dependence of the access to care on the income may look as discrimination against the rest of population. Healthcare will have to solve problems rooted in the socio-economic system.|
|5. European nations privatise all of healthcare, including its funding||The scenario of ‘laissez-faire’ is possible if the governments cut healthcare expenditures. The scenario will finally legalize the conflict of interests of large stakeholders whose objective is profits. As the result, the EU healthcare system will look very much like in the USA. The USA healthcare system is generally recognized as ineffective in terms of health improvement and very effective in terms of profits for large insurance and pharmaceutical companies.|
The situation in the USA deserves a special consideration. USA leads in health care expenditures (17.2% of the gross domestic product), while in terms of healthcare efficiency (life expectancy, prevalence of chronic diseases, etc.) it is very far from the leaders. The USA holds the 50th place out of all 221 countries and 27th place out of 34 developed economies in life expectancy. Out of 17 countries with high income USA has one of the highest prevalence of people with obesity, heart and lung diseases, disabilities, injuries, homicides and car accidents, it has relatively high infant mortality rate. Comparison of healthcare systems in USA and Cuba is very disadvantageous for the former: with very close public health indices Cuba has them with striking 20-fold lower annual per capita expenditures: $414 for Cuba versus $8508 in the USA.
Analytics mention the following drivers of high healthcare costs in the USA:
1) higher drug prices compensations for physicians;
2) less efficiency in the use of equipment and facilities;
3) higher costs of insurance administration (6-fold higher than in other developed economies);
4) substitution of higher-cost services for lower-cost options with minimum increase in benefit;
5) higher prevalence of obesity;
6) low productivity gains in the health care, since providers’ reward is based on volume of services rather than the value of care.
What conclusions can be drawn from the situation in the USA?
1) financial expenditures are not decisive in overcoming the problems of health care; adequate system organization is much more essential;
2) the problems in health care are not solved by high technologies; on the contrary, high technologies may wash-out simpler, more affordable and cost effective ones;
3) the US health care model is cost ineffective in terms of health improvement per investment; the most probable reason is maximum conflict between the interests of stakeholders and the objectives of medicine.
How do analytics see major trends in the US health care? Interestingly, they rather talk not about health care but about health industry, the business made on health. This sector is expected to be turning more and more into a consumer-oriented marketplace.
Here are the major trends in the US healthcare (for 2015):
1) Do-it-yourself healthcare solutions (wider use of devices and applications for remote diagnostics and monitoring);
2) Increase in the number of portable medical devices;
3) Balancing the privacy of health information and convenience;
4) High-cost patients will prompt cost-saving innovations;
5) Increasing demand for evidence supporting new products (drugs and devices);
6) Transparency initiatives targeting clinical trial data, real-world patient outcomes and financial relationships between physicians and pharmaceutical companies;
7) Getting to know newly insured (people who gained access to medical insurance due to Obama’s reforms);
8) Expanded role of physician ‘extenders’ (nurses and pharmacists) in patient care;
9) Redefining health and well-being for the new generation;
10) Joint ventures, open collaboration platforms and non-traditional partnerships across different niches to find new competitive strategies.
As one can see, the forecast made for USA mostly focuses on short-term trends. Unlike the EU forecast, it fails to peer far into the distance, let alone looking beyond the horizon. On the other hand, it looks much more like optimization of business processes than analysis of problems and solutions. Also, the forecast for USA doesn’t take into account the socio-economical context: the debt crisis, the declining trust in dollar as the reserve currency. Since dollar is the major export article for USA, the well-being of US citizens and economy is based on the ability to trade goods and services for dollars made out of air.
Now let’s look at the vision of another key player in healthcare – the business itself: it is described in detail by a review of a new business model for innovative companies, “Owning the disease: A new transformational business model for healthcare”.
The model suggests to integrate within one commercial proposition all solutions related to diagnosing and treatment of a particular disease. This way the patient will receive all services focused on his/her health problem from a one-stop shop, a single provider. Medical technology companies plan to borrow this business model from IT businesses, companies like Apple and IBM that have transformed from equipment manufacturers into providers of integrated solutions.
This model is much more adapted to the challenges of economic crisis, decline in solvent demand and access to financing. According to healthcare payers, today’s innovations should reduce costs and improve the outcomes. The payers also request personalized approach and reward based on outcomes instead of the volume of services. All this is only possible through integration of different elements of diagnostics, treatment and rehabilitation into a single process designed through system approach. Only system approach can at the same time improve outcomes and reduce costs, and operate with limited resources.
The shift from the new model implies change in priorities:
1) selling a solution instead of selling features;
2) a wide system approach instead of limited vision of details;
3) delivering greater value instead of volume-based profit.
“Owning the disease” requires instruments to understand, monitor and influence the patients’ behavior, to coordinate the contributions of all participants, including the medical staff and payers. With this model, the company should focus not on single service but on the entire patient interaction suite: preventative health and wellness; diagnostics; devices; therapies; post-treatment processes; chronic disease management; and even structures for patient interaction and education.
In seeking to own the disease, companies need to build a business model that creates a platform capable of providing a total solution, just as the one provided with iPhone as a hardware platform, the iOS as an operating system, and a commercial platform.
Today none of the companies owns the whole range of solutions for a particular chronic disease. With this, 80% of healthcare costs in the USA are spent on chronic diseases requiring lifelong follow-up. That’s why a company able to create a platform for “owning the disease” will receive a strategic advantage over the competitors.
The described business model holds a definite promise – primarily, owing to the use of a SYSTEMIC approach, i.e. a holistic understanding of a chronic disease as a physical, mental and social phenomenon. However, the concrete examples of how this model is used by pharma companies are quite discouraging. Thus Sanofi decided to get to “own” diabetes while remaining within the old understanding of the mechanisms behind this disease – and hence using unsuitable (in terms of efficiency-safety-price) instruments of treatment.
The chronic diseases that are considered most appropriate for owning the disease initiatives are the following: metabolic diseases (obesity, diabetes), cardiovascular diseases (hypertension, coronary artery disease), neurological diseases (Alzheimer’s, epilepsy), respiratory diseases (asthma chronic obstructive pulmonary disease). Interestingly, these diseases often develop concurrently, complicate each other and cause other complications: for example, obesity is often accompanied by osteoarthritis; most of the listed diseases are accompanied by depression, etc.
Owning Information technologies is becoming an essential asset with this model, improving outcomes at a reduced cost: IT facilitates information media for patients and doctors, accumulation and effective use of experience; through education IT can change lifestyles.
Wide introduction of “owning the disease” in liberal economies will help healthcare businesses survive even in economy downturn. However, will this business model benefit the end consumers, the patients? This seems very unlikely once you recollect the main OBJECTIVE of business: profits. The recent decades have proven that the prerequisite for maximum profits is high prevalence of chronic diseases. The very design of today’s healthcare system incorporates conflict of interests between the objectives of healthcare and the objectives of its major players.
- In analyzing the promising medical technologies, one has to bear in mind the existing pressing problems, the available solutions for them, and the context of progress in medicine over the recent decades.
- Mid-term forecasts for medicine are made primarily by the representatives of the governments and the business community, and these forecasts are made from the standpoint of the corresponding player’s interests. The end consumers have their own opinions that reflect their unsolved problems (ineffective-unsafe-expensive); and this opinion translates into choosing particular affordable and accessible methods, including those of alternative medicine.
- The forecasts related with the use of digital/information/big data technologies in medicine are quite realistic. However, these technologies cannot enable breakthrough solutions for the main problems in medicine, because the content of the information used in these technologies is rooted in inadequate practical understanding of health as ‘normal physiological parameters’ of the body.
- Most of the optimistic forecasts related with already existing or emerging “breakthrough” medical technologies (gene therapy, personalized and ‘smart’ drugs, etc.) represent wishful thinking and fail to consider the systemic nature of both human diseases and the problems of today’s medicine. Bearing in mind the socio-economical context (recession and numerous global challenges), active development and wide use of expensive technologies seems very doubtful.
- In-depth systemic forecasts for the EU are mostly pessimistic in terms of new medical technologies; they rather rely on optimization of health care structures. They all suggest a higher role of prevention and ‘do-it-yourself’ technologies of health control.
- The example of USA is very useful in the following way: the liberal model of healthcare demonstrates very low cost effectiveness and even doubtful overall benefit for the consumers (just recollect the rate of iatrogenic deaths in the USA). Financial injections, decisive for technology progress, are of very little use in overcoming the drawbacks in healthcare; adequate organizational solutions are much more effective.
- In the context of liberal healthcare model, when healthcare is actually replaced by health industry, businesses sees a promise in the model of “owning the disease” which enables attaining the business goals – maximum financial profits. However, this business model cannot remove the conflict of interests from healthcare, and thus it will hardly be useful to the end consumers and the society in general.
As the reader can see the review of promising trends in the medicine of the 21st century has revealed a very contradictory pattern:
(1) consumers and governments whose major problem is a triad ‘ineffective-unsafe-expensive’ view the future of medicine not as development of new medical technologies but as a higher role of prevention and as improved design of the healthcare system itself.
(2) development of new technologies within today’s biomedical paradigm (stating that human=physical body, health = normal physiological parameters) seems promising and beneficial to only developers of those technologies.
(3) the situation is aggravated by the economic crisis putting the cost issue at the top; hence, the first candidate for reduction are costly new technologies that have not proven their benefit yet.
The reader will very likely ask the ensuing question: WHAT CAN BE DONE?
We are as yet not ready to address it before finding the answer to the following key questions: WHAT CAUSED THE SITUATION AND WHAT IS MAINTAINING IT?
I think I have spotted the causes and drivers of problems. They will be addressed in the next part of this essay.
Here we’ll look into the mechanisms that hinder medicine from developing as an activity designed to maintain and restore human health.
I see three major layers of problems:
- at the level of organization and economics of the healthcare system;
- at the level of prevailing scientific concepts, theories, models;
- at the level of world view of professional and expert communities.
Let’s examine them one by one.
- At the level of organization and economics healthcare system contains a conflict of long-term interests of the stakeholders determining the POLICIES in healthcare. What is this conflict about? Everything is quite obvious once you compare the declared objectives of medicine with the objectives of pharmaceutical companies and real interests of medical professionals.
The objective of medicine is to maintain and improve health (which is, by the WHO definition, physical, mental / psychic, and social well-being). The objective of pharmaceutical companies as commercial entities is profit. The issue of doctors and other professionals is a bit more complex. On the one hand, they may be sincerely devoted to the ‘lofty ideals’ of helping people; but from the viewpoint of economic interests, doctor’s income is proportional to the volume of services provided to the patients, and not to the patients’ health. Correspondingly, less diseases in people would in the long-term … threaten the doctors reduced income or even loss of their jobs.
On the other hand, over the last decades all concepts, theories, standards of care and education have been formed under direct control of the companies that develop and manufacture the major tools used in medicine – namely, drugs, new diagnostic and therapeutic technologies. If you look at the budgets that large pharmaceutical companies spend on development and promotion of their products, they will be comparable with budgets spent on research by whole countries and even regions. For example, government expenditures on research in health care in Europe amount to 0.15% of GDP on average (source), which is in money terms amounts to about $25 billion. Compare this with the opportunities of large pharma companies: sales of only one company Johnson & Johnson exceeds $70 billion, while overall sales of twelve largest pharmaceutical companies exceed $500 billion. Bearing in mind that research, marketing and management take about 45% of the revenues (source), the financial resources of pharmaceutical companies to promote their products and ideology are 10-fold larger than the money spent on medical research by ALL EU MEMBER STATES – the second richest world region after USA. The real influence mechanisms on decision making in healthcare, on research institutions, universities, professional associations, as well as on doctors and pharmacists are described in several books. The most well-known of them are «The truth about drug companies: how they deceive us and what to do about it» by Marcia Angell, and «Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients» by Ben Goldacre.
More than $ 100 million are spent annually by pharmaceutical companies to lobby decision making in only the US Senate (source). A good review of manipulations done by pharmaceutical companies in the field of Evidence-Based Medicine can be found here.
This way, in the established health care system the decision making process at the level of governments, the opinions of the expert community, educational programs, diagnostic and treatment standards are shaped under the influence and for the benefit of the largest stakeholders – primarily, the large pharmaceutical companies. And since the major objective of pharma is profit making, there is nothing amazing in the fact that everything that goes on in healthcare is in some way under the command of this objective.
This is a picture drawn from the standpoint of common sense and logical cause-effect relations.
What is the mechanism by which the interests of “commercial” stakeholders of healthcare are integrated in the ideology of medicine? Let’s look into the more long-term influence on the ‘minds’ – most importantly, the minds of the professional community. This influence produces effects that last for decades.
- The problem at the level of scientific concepts, theories, and models.
The cornerstone of today’s biomedical science is the following postulate outlined for example in a 2000 review on cell signaling entitled “Signaling Networks”, a 2006 review on pharmacology entitled “The future of pharmacology”, a 2010 review on biochemistry entitled “The Chemical Basis of Pharmacology”, and dozens of other papers. It can be summarized as the following phrase: “regulation of physiological processes can be reduced to chemical signals”.
One of good recent examples can be found in the following 2014 review on cell physiology:
“We are constantly receiving and interpreting signals from our environment, which can come in the form of light, heat, odors, touch or sound. The cells of our bodies are also constantly receiving signals from other cells. These signals are important to keep cells alive and functioning as well as to stimulate important events such as cell division and differentiation. Signals are most often chemicals that can be found in the extracellular fluid around cells. These chemicals can come from distant locations in the body (endocrine signaling by hormones), from nearby cells (paracrine signaling) or can even be secreted by the same cell (autocrine signaling).”
As you can see, no place is left WITHIN THE BODY for other signals than chemical, while the author is very well aware of the diverse nature of signals carrying information for the whole organisms.
This very postulate forms the FALSE FOUNDATION for all other “generally accepted theories” in today’s biomedical science. The further logical construction can be easily reproduced:
- The whole regulation in the body is mediated primarily by molecular (chemical) interactions — chemical signals. (“Primarily” means in practice that all other interactions can be disregarded.) Regulation of any physiological process involves a stage of binding a signal molecule (ligand) to a specific receptor.
- In any disease, an underlying impairment of chemical signaling can be revealed: it can be either down-regulated or up-regulated.
- Development of any disease can be influenced by stimulation of the corresponding chemical signal, if the signal is down-regulated, or by suppression of the signal, if it is up-regulated. For this purpose, a chemical stimulator (agonist) or blocker (antagonist) of the corresponding receptor should be introduced.
- The described model logically implies that if a substantial dose of a chemical or biological agent, an agonist or antagonist of some receptor, is not introduced in the body, it is impossible to influence regulation changed due to a disease.
The given model serves as the foundation for today’s pharmacology and drug treatment of diseases. The model set forth in the late 1930-s has determined the conceptual framework of today’s physiology and molecular biology. What is its major benefit? If all diseases can only be treated by chemicals then all new drugs can be patented – that is, the patent holder can have a monopoly in the market and sell these drugs at a voluntary high price. This is exactly the model of business and super-profits of large pharmaceutical companies (“the Big Pharma”). After patent protection expires, generic copies that flood the market are sold at a price many times lower than the “original brand”.
What is wrong about the described model of body regulation? The answer is quite simple. In reality, chemical signals make up only A MINOR part of intercellular interactions within the body. A similar or even more important role is played by the signals of physical nature (biophysical). Why do we state this so assertively? There are at least three major arguments:
(1) the structure of information that the whole body exchanges with its environment and the cell exchanges with its environment is similar;
(2) the efficiency of information exchange through chemical signals (energy costs, speed, etc.) is incommensurably lower when compared with physical signals;
(3) all organs and cells of the body have structures and mechanisms that provide exchange of physical signals in the course of physiological regulation.
Each of the above arguments deserves detailed explanation which will hardly fit in the frames of either this essay or even a large scientific review. Below I’ll try to explain each thesis with available analogies.
(1) Similarity between the cell and the whole body. Look at the range of tasks that each cell has to solve in order to survive and function properly: it can hardly be distinguished from that of the whole organism. This topic was developed in detail by James Grier Miler, a US psychologist one of the founders of the systems approach in biology. He proposed the list of 20 major functional subsystems present at each of the seven levels of living systems organization. Just imagine for a second that the whole organism is limited in the range of signals it perceives from the environment to only chemical ones: smell and taste. Are you ready to live without vision, hearing, sense of touch, proprioception? Are you sure you’ll be able to survive? And why does science deprive the cell of the ability to perceive electromagnetic and mechanical vibrations?
(2) The efficiency of chemical and physical signals. Everyone who completed the course in biophysics would know that perception of physical signals is based on the mechanisms of resonance – a phenomenon that occurs when the frequency of an external signal coincides with the intrinsic frequency of the receiver. The speeds of chemical interaction and resonance-based interaction were compared in 1974 by a British physiologist Colin McClare in his paper “Resonance in bioenergetics”. What did he find? The time spent for energy exchange through resonance mechanism compares with the time spent for chemical interaction something like 1 second compares with 30 years (1:109). And yet this comparison doesn’t include the time necessary for diffusion, nor the time and energy costs necessary for the synthesis of the signal molecule if we speak about substances produced by the cell.
With this comparison in mind, which way of information transfer would the living system prefer: the fast and cheap one like a broadband Internet or the slow and expensive one like golden tables transported by camels? Most probably, golden tables have a certain very limited role in information storage.
(3) The structural organization of the cell. The cell has all necessary structures unique in their efficiency to perceive and transfer electromagnetic and mechanical signals. The best studied signals of this kind are biophotons. Those who would like to read more about this topic, can access a selection of research papers. By the way, in their conductivity for biophotons cytoskeleton (microtubules) and connective tissues (ligaments, tendons, etc.) are very similar to fiber optic cables, hence the earlier analogy with wide-band Internet connection is relevant.
As you can see, science is aware of the structures and mechanisms that provide physical signaling in regulation of physiological functions. What are the implications? How actively are these subjects studied? A search in the largest biomedical data base PubMed has retrieved miserable 5273 papers with key words “electromagnetic cellular interactions“ over the last 38 years (for those who are interested I’d recommend a recent review article on the subject). To feel the difference, there are more than 174 thousand published papers with key words “ligand receptor interactions”, 213 thousand papers for “receptor signaling”, 124 thousand papers for “receptor antagonist”, and so on. This fact shows that the scientific efforts and resources focused on the research of the most important regulatory mechanisms are many hundreds times, if not thousand times, weaker that those focused on the study of chemical signals. What’s more, if you look into the details of that handful of papers on non-chemical mechanisms, it would be obvious that none of them are focused on the development of the tools TO INFLUENCE those mechanisms, nor methods of diagnosing, treatment or prevention of diseases involving those mechanisms. To put it briefly, none of these papers have any APPLIED FOCUS.
Thus we have briefly examined the fact that today’s pharmacology and physiology are based on a false postulate on the key role of chemical signals in the regulation of physiological functions. Regular research into NON-CHEMICAL signals which actually play a much more important part receives less than ONE THOUSANDTH of efforts and resources in biomedical research. Obviously, if some field is not studied it would remain a blank space. A conspiracy question inevitably comes to mind: “Who is to profit?” The answer is obvious: those stakeholders in medicine who profit from sales of drugs made of patented chemicals.
Now it’s time for the last, the deepest ‘layer’ of the hurdles that impede progress in medicine.
- At the level of world view, the members of professional and expert societies lack system approach to the human, to health and disease.
We have already cited the WHO definition: health is «a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity». We have seen that just like human cannot be reduced to physical body, health cannot be reduced to normal physiological parameters. What goes on in real life?
In their real practice doctors, scientists and experts demonstrate a distortion at the level of world view: they fail to treat humans as a system, as an organizational level of living systems. The founder of systems biology, James Miller marks out seven organizational levels in living systems: Cell, Organ, Organism, Group, Organization, Society, and Supranational System. Without system approach it is impossible to understand the human nature that involves:
- the physical principle (organism and lower levels of organization),
- psyche – mind (structures key for interactions between individual people), and
- the spiritual principle (structures and rules governing the interaction between a person and higher levels of living systems’ organization).
The research of human is divided into separate and very often contradictory branches of knowledge. Thus, the physical body is studied by biology and medicine. The psyche (mind) is studied by psychology, a little bit by psychiatry (a medical specialty), a little bit by philosophy, by numerous religions, and esoteric schools. The processes in the society, the higher hierarchical level of the human, are studied by sociology, a little bit by psychology, by political science, by economics…
And representatives of each given science have almost no idea about the others: for example, sociologists and philosophers know very little about biology; doctors are unaware of the issues of spiritual development, etc. As the result, each given expert doesn’t have and cannot have a systems vision of the processes and problems – and hence cannot have the keys to finding the solutions.
Meanwhile, the principles underlying the functioning of healthy living systems at different levels of organization are UNIFORM; these principles are pretty well described, and without addressing them in the structure of healthcare, reaching the declared goals of healthcare is hardly possible.
I’m not sure if the question “Who is to profit?” is as relevant for false world view as it is for healthcare economy and ideology (false scientific postulates). However, distortions in economy and ideology cannot exist without long-term and stable distortions in the world view of the elite, including the expert and business communities.
What is the world view that replaces holistic understanding of human as a living system? This ideology is called individualism. Its essence is the notion that interests and value of an individual should achieve precedence over the value and significance of society in general.
From the viewpoint of living systems, individualism is something like significance of a separate cell precedent over significance of the whole organism. This sounds absurd. Each individual cell is of value for the organism, however, individualism at the level of cells threatens death to both the whole organism and all its individual cells. And in the same way, individualism as the prevalent world view threatens death to both the society and all its members.
Individualism is a major part of today’s liberal ideology dominant in so-called “developed economies” and actively introduced throughout the world. From the standpoint of living systems, liberalism and individualism are the principles of organization and interaction which are most destructive for any living system, including the humankind.
In my opinion, wide spread of an adequate world view is a threat to today’s world rulers – in the first place, at the level of transnational corporations and their beneficiaries. This is no longer a secret that the major part of world’s wealth is controlled by a narrow circle of financial institutions (see a diagram below taken from the published paper), let alone all consumer goods (reference to the US example).
Someone can call this way of thinking conspiracy. However, this is only the logic of control revealed by systems approach.
Now let’s sum up and formulate briefly the hidden hurdles that impede progress in medicine. They appear as a three-headed monster:
Profit as the real interest of the most powerful stakeholders in healthcare is very poorly compatible with the objectives of healthcare itself. All decision making, experts’ opinions, standards of education and medical aid – all this is very easy to influence with tremendous financial resources. This way pharmaceutical business which had originally emerged as a tool for medicine, became the true owner of healthcare.
Profit as the major objective excludes preservation of health from the goals of medicine, or at least places this goal under command of financial goals. As the result, health is no longer a true public priority neither in the short nor in the long term.
At the level of people and organizations this problem is seen as the conflict of interests. This is the major ECONOMIC hurdle for progress in medicine (medicine, not business made on health). This hurdle is the most “tangible” one – and that’s why the beneficiaries cannot rely on it alone: it is too visible.
The IDEOLOGICAL HURDLE. Close examination of the fundamental axioms forming the basement of today’s biomedical science reveals a curious finding. The ideological structure of the medical science has an in-built brake, restraint that makes it impossible to develop and introduce novel medical technologies which
a) cannot be controlled by a monopoly,
b) are not profitable, and/or
c) cannot be monetized (are difficult to turn into a large-scale business).
This brake is a false assumption of how the body is regulated. The cornerstone on today’s biomedical science is the following axiom: “regulation of physiological processes can be reduced to chemical signals”. This axiom give rise to all prevailing concepts of both disease mechanisms and approaches to diagnostics and treatment. This axiom directly implies that without introducing in the body some chemical compound (the source of chemical signal) one cannot influence diseased regulation in the body. HOWEVER, chemical signals hardly account for more than 10% of the mechanisms that body uses to regulate itself; the rest are signals of physical (biophysical) nature. This is a complex issue deserving a separate detailed discussion.
This axiom has the following practical implications for the beneficiaries:
a) the use of pharmaceuticals can be controlled by a monopoly (through patenting);
b) development and wide promotion of “unscientific” competitive methods can be reduced through limited financing;
c) the developers and followers of “unapproved” methods can be suppressed.
As a result of the described brake, the effectiveness of biomedical sciences is very limited: essentially, the research can only be done in the “approved” fields, and not in the fields where solutions can be found. This tacit ban on the studies of biophysical regulatory mechanisms is backed up by certain ideological restrictions in physics.
The METHODOLOGY HURDLE. Finally, progress in medicine as the major science about health is impossible due to the actual rejection of systemic approach to a human as a trinity of physical, psychological and spiritual elements. The whole system of knowledge about human is split into unrelated and contradicting disciplines (physiology, psychology, sociology, etc.), and the representatives of each given discipline are unaware of the conceptual framework of the others. Due to this split neither the fundamental science nor applied sciences fail to consider and use the principles of living systems – the principles common for all the levels of human organization.
The systemic approach to human has been replaced by individualism – the position “self comes first” which contradicts both the principles of healthy living systems and the systemic understanding of the human nature. This replacement is especially devastating within the elites where decision making takes place in all fields including medicine.
Therefore, the source of problems in today’s medicine is triple:
- At the level of world outlook of the professional and expert communities: Individualism (and liberalism) as the system of beliefs contradictory to the principles of healthy living systems and incompatible with systemic and holistic understanding of the human nature.
- At the level of dominating scientific concepts, theories, and models: At the level of the scientific ideology, the expert community demonstrates an artificially introduced false understanding of how the body is regulated. This false scientific model prevents the search of effective solutions for medical problems and guards the economic interests of a small group of key players in health care.
- At the level of organizations and healthcare economy: Prevalence of individualism results in неразрешимый conflict of economic interests across the key players of health care. The only possible result of this conflict in individualistic persons is that drive for profit (enrichment of minority) prevails over the benefit for society in general. The conflict can only be maintained with dominance of the false scientific ideology.
Now, as we have revealed the major problems underlying the current sad situation in healthcare in general and medicine in particular, there comes an opportunity to overcome it and answer the question: “What can be done?”
Since the current state of affairs has been developing for over a century, it cannot be improved overnight.
Also, there are too many powerful beneficiaries that are interested in current situation to be maintained, and they have all necessary leverages to support it. Here is a brief list of groups too interested in status quo and too deeply involved in it to let the situation change:
(1) stakeholders of pharmaceutical and other businesses in ‘health industry’;
(2) decision makers in the governments controlled by group (1);
(3) expert community controlled by group (1) and justifying decisions made by group (2);
(4) medical professionals who are hostages in the trap of false world view, false scientific concepts, and conflict of interests.
Healthcare is a part of a larger system – economy, society in general. That’s why a major improvement in healthcare is impossible without improvement in economy and society.
What is the major problem of today’s economy? Just like healthcare, economy in general is designed to serve the interests of people. Just like healthcare, economy has its major players (stakeholders), including the lay people, the state, and the businesses. However, unlike healthcare, the structure of today’s economy openly implies that those who control the finances can impose their interests on the others. Many people today are aware that most mid- and long-term decisions in most countries are made for the benefit of the global oligarchic corporatocracy. In particular, a good example of corporatocracy in the USA is lobbying, the legalized corruption.
Is it possible to improve the situation in healthcare while the world economy in general and national economies are managed for the benefit of corporations, while national elites act for the benefit of foreign countries or transnational / supranational structures? Very unlikely.
That’s why the first step to improve the healthcare should rather be changing the rules of the game in economy in general. What might be the “new rules”? The following opportunity will be discussed with regard to the situation in Russia.
Perhaps, as the first step, the following three key axioms should be adopted relating to the world view:
(1) Human society, just like any human individual, is a living system; to stay healthy, human society and individuals should keep to the principles of healthy living systems.
(2) Today’s ideology of liberalism and individualism that define the rules in the society and economy in particular, is in deep conflict with the principles of healthy living systems. The consequence of these ideologies being dominant over the last century is the current world crisis which is only gaining strength. The potential impact the crisis may have on the most ‘liberal’ countries is least predictable.
(3) To overcome the world crisis, nations have to revise the dominant ideology that governs decision making by national elites. As a provisional version, the principles of healthy living systems discussed here above might be suitable. They are fully compatible with the national idea recently proposed for Russia – the idea of patriotism; they provide enough space for development and detailed elaboration.
What can be done further, after the new “official ideology” is adopted?
Then the principles of healthy living systems will have to be implemented through a long-term and laborious work. When applied to medicine, just like to any other branch of economy, gradual reforms should involve the three general levels of control: (1) methodological (dealing with world view), (2) ideological (dealing with facts), and (3) economical.
Below is a brief road map for the mentioned levels.
(1) methodological level:
— Curriculum of all educational institutions (first universities, later on colleges) should be supplemented with a tutorial on living systems / control in living systems. This tutorial should help the young people to develop a holistic comprehension of human, to understand the close connections between various life phenomena, to master the principles of control over their own lives. This tutorial can cover and synthetize a wide range of information from currently separated disciplines like biology, psychology, sociology, economy. Its objectives will include development of patriotic world view in line with state ideology of patriotism. Sketches to this tutorial and be found here (so far only in Russian).
— The principles of secondary and higher education should be revised: the major objective of education should become the most complete realization of creative potential by every individual for the benefit of the whole society.
— The efficacy criteria for any economic activity should be revised: instead of today’s monetary criteria they should be based on the ability to meet demographically reasonable needs of people and society in general with the least expenditure of resources.
(2) ideological level (applied to medicine):
— the scientific model forming the basis of today’s biomedical science should be acknowledged as unfounded (at least as limited);
— all basic and applied schools and approaches in medicine, both ‘mainstream’ and those termed as “alternative”, have to be reviewed in terms of their efficiency in real practice (including cost efficiency);
— the methods of prevention and treatment of chronic diseases that have proven efficient in real practice, affordable and cost effective should be introduced and encouraged most widely; doctors should receive training in these methods.
— the focus of doctors’ activity should be shifted from “repair” (suppression of disease symptoms) to education – teaching the patients to heal independently. Introduction of holistic approaches to human and diseases into medical education should help in this focus shift.
(3) economic level of control (applied to society in general):
— the economy should be freed from all kinds of activity and products that have a negative impact on the health of individuals and society in general (including parasitic types of activity like usury);
— since the major factor of chronic diseases is chronic stress related with uncertainty in future, it should be put under close control. In line with this, the basic economic relations in the society should be changed to guarantee vital (demographically reasonable) needs of each individual.
(3.1) Economic level of control applied to medicine:
— general pattern of relations (“the rules of the game”) in medicine should be changed in order to remove any conflict between the objectives of medicine and the interests of its stakeholders;
— the commercial nature (motivation focused on profit) should be removed from the activity of all healthcare players;
— the function of development, manufacturing and distribution of the “instruments” that medicine uses should be put under control of society (government);
— the income of doctors and other healthcare professionals should be put in relation with the state of HEALTH of their patients.
An important feature of the changes is to HOW they have to be implemented. In choosing the methods of implementing the reforms the following principles should to be kept in mind:
1) Choose consecutive steps, each one should bring the situation towards the goal as much as possible at the least possible costs.
2) Make allowance for inertia and resistance of all the parties involved, and use motivation for change (like drive for upward social mobility, long-term career goals, opportunities for creative self-realization, financial incentives and penalties).
3) Each of the mentioned control levels has its specific features: the methodological level requires most long-term efforts but provides the most stable results; the economic level gives rapid but rather superficial results, and can cause active resistance.
4) Two parallel processes of reforms should be combined: “top down” (through changes in “the rules of the game”, regulatory mechanisms, etc.) and “bottom up” (through changes in individual information state and daily practical solutions of real problems for real people).
And finally, the most intriguing question:
It goes without saying that the above-mentioned “top down” reforms require a significant political will at all levels of state authorities, a lot of highly qualified administrative staff, material and intellectual resources. And what can EACH PARTICULAR PERSON do? What is that “bottom up” process?
Luckily, there is a “bottom up” solution; it is available to anyone who would like to get rid of dependence on drugs and doctors, especially in the treatment of chronic diseases.
This solution is available on one condition. It is — readiness to learn, to acquire new knowledge and apply it in practice. I have designed a separate section on this site (so far in Russian only) for those who would like to get acquainted with a universal self-treatment approach and master it.
A sort of “bottom up” approach to one of the most acute problems of today’s medicine – oncology (cancer) – has been proposed by the authors of medalternativa.info. There are many doctors practicing alternative methods who are ready to share their knowledge.
The society in general and especially doctors are badly in need of information helping to improve their world view and discover new opportunities. Such information does exist and this web site is designed to open it to general public.
If you would like to contact the author, send an e-mail to: avmp2007(at)mail.ru