   |  | | Can our system transform fast enough to catch up to our science? | By Mike Magee, MD
The people, and the people caring for the people, in the United States and around the world are just beginning to absorb what the term “preventive health care” really means. Until recently, it was enough, most thought, to know that it was different from our current approach -- that being the ability to react to and control the effects of chronic disease, or rescue someone in the case of a medical emergency.
Now, as we awaken to a brand new scientific era filled with an array of brand new diagnostics and soon to be therapeutics, the public and their caregivers are beginning to dial back to better understand the kind of system required to accommodate and benefit from these new tools.1,2,3
Prevention is, in one word, planning. To stay ahead of disease, and possibly eliminate its emergence completely requires anticipation. If one is, for example, to preempt diabetes, steps must be taken to protect and enhance pancreatic cells that produce insulin for an anticipated lifespan today for a newborn of 100 years. Preventive care planning must begin at conception and extend out for at least a century beyond birth date.4
Within this construct, our current health care system’s power axis - the hospital-to-doctor's-office-to-hospital loop - is ill-prepared (at least today) to assist in home-centered, family based health planning.5 Advanced thinking on the Medical Home concept by organizations representing the nation’s family physicians, internists and pediatricians have begun to address that structural deficit, at least in theory.1,2,3
To illustrate the challenge that lies ahead, one need only to look at the advances in the Human Genome Project with original breakthroughs at the turn of the past century.6,7 Now, nearly a decade later, Elias Zerhouni, head of the National Institutes of Health, has laid out his own "Vision for Transforming Medicine in the 21st Century."8 In it he describes the future genetic-aided approach with 4 P's: “predictive, preemptive, participatory and personalized.” What does he mean?
He is reflecting a now widely substantiated belief that our genetic makeup profoundly determines the likelihood of our suffering in the future from chronic diseases such as cancer, mental illness, diabetes, heart attack and stroke. He is also suggesting that early knowledge of personal vulnerability, applied now with an eye toward the future, could potentially put families and their caregivers in a position to not only keep diseases at bay, but prevent them from ever occurring at all.4,8
This promise cannot be fulfilled without further scientific and organizational progress. Said in another way, new discoveries must be validated and evenly distributed through a reliable and accessible nation wide health care system. Let's look for a moment at genetic testing. It requires a move toward excellence on four different fronts. First, the use of universal fetal and newborn testing to identify relatively rare congenital diseases. Second, testing at birth to identify those most at risk for common early childhood diseases like middle ear infections. Third, childhood testing to identify predisposition for future chronic problems like high cholesterol induced heart disease. Fourth, testing to define what might be the most effective medicines personally for each individual if in the future they are challenged by a disease.9
By now, it is widely recognized that maintaining health and preventing disease involve not only science and genetics, but also a range of social and behavioral factors, environmental conditions, and timely access to quality care.10 What we are just beginning to realize is that early diagnostic testing, even at times before birth itself, may help direct planning efforts on behalf of those about to be born. Such children will arrive with a distinct advantage. Vigilant parents and engaged caregivers will be armed with customized and personalized health planning tools, and will be highly motivated to adhere to agreed upon plans. Why? Because adhering in the future will mean not simply controlling a disease, but rather preventing it from happening at all.
There are challenges that remain, of course. Tests must be proven accurate and reliable. They must be proven to be predictive of future pathologic changes. And behavioral adjustments and therapies must be proven to improve health outcomes.9 Beyond this, policy adjustments to ensure full legal protection against any and all forms of discrimination must be iron clad.11 But these challenges will no doubt be met within the short term. The greater question is whether a new preventive health care system with national capacity and reliability can be constructed over the next four to eight years to support such an optimistic vision.
References:
1. Arvantes J. Patient-Centered Medical Home is Key to Health Care. American Academy of Family Physicians. 14 May 2007.
2. American College of Physicians. The Advanced Medical Home: A Patient-Centered, Physician-Guided Model of Health Care.
3. American Academy of Pediatrics. What is a Medical Home? 17 March 2008.
4. Eriksson JG. Gene polymorphisms, size at birth, and the development of type 2 diabetes. J Nutr.2007;;137(4):1063-1065.
5. Magee M. Home-Centered Health Care: The Populist Transformation of the American Health Care System. Spencer Books, 2007. NY, NY.
6. Lander ES. et al. Initial sequencing and analysis of the human genome. Nature. 2001;409 (6822): 860-921
7. Venter JC. et al. The sequence of the human genome. Science. 2001;291(5507): 1304-1351.
8. Zerhouni E. A vision for transforming medicine in the 21st century. Posted Sept. 13, 2006.
9. Cheng TL et al. The Genetics Revolution and Primary Care Pediatrics. JAMA, January 20, 2008. 451-453.
10. McGinnis, JM. et al. The case for more active policy attention to health promotion. Health Affairs (Millwood)2002;21(2):78-93.
11. Emery J, Hayflick S. The challenge of integrating genetic medicine into primary care. BMJ 2001;322(7293):1027-1030.
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