March 3, 1998
by Konrad M. Kressley
This is the seventh in a series of articles on what to expect in the next millennium. If you've read prior installments, you know that technology trends are the principal force that augur future developments. Humanity is now experiencing the so-called "Third Wave" or Information Age launched by the invention of computers. These thinking machines are important not only for themselves; they enhance and transform other technologies as well. The resulting advances touch all aspects of our lives, including health care. Using the context of 21st century demographic and economic trends, let us attempt to forecast central issues to be faced in the next century. A word of caution: this article does not seek to describe or laud specific medical technologies, you can get that from Newsweek or Parade magazines.
Before we turn to the future, it might be instructive to review developments that led to the current state of the U.S. medical industry. Until approximately mid-century, health care was essentially a small business based in the homes of individual physicians. Hospitals were charitable or community institutions. Then, the twin forces of insurance coverage and modern medical technology transformed black-bag medical practice into a corporate industry. To begin with, the economic boom after World War II translated into higher wages and benefits for industrial workers. Health insurance was one of those benefits. With an insurance card in a wallet or purse, individuals essentially handed physicians, hospitals and other medical specialists a blank check, which translated into the best medical care available. Remember that medical procedures are different from other goods and services, where the customer shops for price and quality. Here the doctor determines what you need and how much it will cost. It was not unusual for patients to get more than they needed. Since the late sixties, government Medicare and Medicaid programs made more people eligible and pumped additional money into the system.
The same era witnessed a technological revolution in medical care. Advances in microbiology, chemistry, engineering, and electronics were incorporated into medical science. For instance, kidney dialysis became possible with the development of filter membranes, gastroenterology flowered with the invention of fiber optics, and heart pacemakers came into existence with miniaturized electronics. While technology innovation is a common thread of contemporary history, the experts agree that the availability of private and government health insurance money accelerated the pace of high-tech medicine. In the process, health care became extremely profitable. Competition followed. Now private-practice physicians and community hospitals are being swept away by corporate medical conglomerates organized along industrial lines for efficiency and profit. You might say that health care is finally catching up with the business mainstream where stores, restaurants, auto service shops and nearly all other enterprises operate on a large scale and are organized into regional, national and even international chains. Now it's health care's turn for the corporate makeover with all the down-sizing, mergers, acquisitions and financial acrobatics that come with it.
So what does this mean for you, the health care consumer? First of all, start thinking about health in economic terms or how folks can maintain optimum health at a minimum price. Currently, fee-for-service private physicians are being replaced by managed-care facilities called Health Maintenance Organizations (HMOs). Employers, private individuals or insurance companies pay fixed monthly fees for a total package of medical services. The operation turns a profit when the fees exceed actual expenditures on the HMO's clients. Assuming that there are many competing HMOs, you can shop around and pick one with the best reputation and lowest fees. At the same time, the HMOs maximize profitability by enrolling healthy clients and keeping them in tip- top shape so they won't need costly medical procedures.
It sounds like a win-win situation. Everyone is motivated to save money and stay healthy at the same time. The HMOs, particularly, encourage wellness by emphasizing regular exams, preventive care, and educating clients about a healthy life style, all of which is good for them anyway. So what's the problem? First, managed care organizations steer away from folks who are likely to need frequent and extensive medical care. Consequently, those with the greatest need are often denied coverage and left to fend for themselves. Secondly, managed care involves a system of rationing, where all possible afflictions have a coded price tag that the health care provider is loath to exceed. That makes good sense to the corporate medical executives, but can be quite frustrating for an individual whose life depends upon an organ transplant or other costly procedure.
Did you know that a dramatic turn-around in the causes of death and disease was recently recorded? For all of history, the cause of death and illness could be primarily be traced to communicable microorganisms; now, however, most people are afflicted by other factors such as hereditary predisposition, environment, and lifestyle. We are talking about cancer, heart disease and emphysema, to name only a few. Serious communicable diseases such as AIDS, Ebola Virus and Mad Cow Disease grab the headlines because they're relatively rare. Meanwhile, we shrug off heart disease and cancer which kill millions. It's a new ball game: before the advent of microbiology, people were essentially helpless victims of infections; doctors could do little except offer comfort while nature took its course. Nowadays, a nearly complete understanding of communicable disease transmission, coupled with vaccination and vastly improved sanitation, has cut the incidence of death and suffering dramatically. Many of today's killers are no longer random germs looking for a victim, but physical disabilities traced to life style or hereditary predisposition. Life style, of course, is largely a matter of choice, and individuals have incentives to maintain good health. Genetic predisposition, though still murky, is in the process of being deciphered so that widespread medical intervention will soon be commonplace. In other words, health-care authorities of the future can take an "upstream" approach to disease, the ability to identify and deal with problems before they become chronic.
Genetic engineering, sometimes called biotechnology, represents one of the most dramatic scientific breakthroughs of our era. As described in an earlier article of this series, scientists now understand the mechanism of heredity, and are working on ways to manipulate the chemical building blocks of inherited characteristics. While cloning has gotten the most attention from the media, other potential applications are far more dramatic. Laboratory experiments show that it is possible to switch genetic materials between species, and even between plants and animals. So, for instance, common bacteria have been "engineered" to produce insulin for diabetes patients, while milk cows of the future will be able to produce a wide range of pharmaceuticals in this fashion. Now, think of other applications. It will soon be possible to alter or even design new varieties of plants and animals. While this is extremely controversial, people are already patenting these mutants. A new strain of bacteria that "eats" dangerous organic chemical waste is one example.
Let's stick with the biomedical uses of biotechnology. One application now in the laboratories would allow us to grow replacement organs and body parts in a test tube or on host animals bred for this purpose. Then there is the matter of hereditary disease. Up to now, people identified as carriers of defective genes were discouraged from having children, or at least told to get fetal tests to determine if the baby would be normal. As you read this, scientists are pin- pointing ever increasing numbers of afflictions with a genetic basis. Now, medical researchers have begun to substitute healthy genetic materials in peoples' bodies. While everyone wants a healthy baby, why stop there? During the elimination of a hemophilia gene, thoughtful parents might also want to do something about their kids' predisposition for obesity, baldness or that rumored "gay gene." Even the human aging process has a genetic component. After a long search, Japanese scientists recently reported finding a distinct "longevity gene," which differentiated most centenarians from the population mainstream in their country.
Assuming that the present pace of discovery is maintained, I predict that genetic solutions to many diseases will be part of the medical mainstream in the next two or three decades. Now comes the interesting part: Once we have helped individuals achieve a longer healthier life by fixing genetic defects, why not use the same technology to create genetically enhanced people in terms of physical and mental capability? Unless you believe that the present state of mankind is perfect and immutable, there is no reason to believe that the ultimate results must be harmful to society. As the prospect draws nearer, politicians, religious leaders and medical ethicists are understandably alarmed. There is reason to be concerned about whose purpose or agenda will be served in the process. While America has often led the way in basic research, Europeans or Asians will be likely be the first to implement genetic improvements. Thus, whether we like it or not, it is probably inevitable that the human species will gain some control over its own physical destiny. The future, you recall, is a matter of choices and not preordained events.
A riddle: What do Twinkies, bungee jumping, and risky sex practices have in common? You guessed it -- all blend pleasure with the probability of illness or premature death. Even the best possible genetic predisposition cannot protect people from a self-destructive life style. Whether through education or pressure from Health Maintenance Organizations, Americans are starting to take better care of themselves. The results of improved nutrition, weight control, exercise, cessation of smoking and alcohol abuse are starting to show up in health statistics. Cancer and heart disease rates are down, while longevity is steadily inching upward.
Until now, life style was a matter of personal choice, an integral part of America's celebrated civil liberties. The human body was like a car, driven until something went wrong. At that point the doctor, like a good mechanic, was expected to fix the body and put it back on the road. Now the rules are about to change. The managed-care approach to health care requires continuous maintenance, check-ups and "safe driving" of the body to avoid costly repair bills. Those who disobey the rules, such as smokers, will be required to pay additional premiums to cover the anticipated higher health-care costs. Others may even be expelled from their health plans. While this is alarming from the standpoint of individual liberty, our growing knowledge of genetic predisposition creates even more chilling prospects. Medical records of the future will feature not only past illness, but also future prognoses, such as Alzheimer's, based on genetic and hereditary analysis. Employers, life insurance companies and health care providers will want to use this information as a screening device to keep out losers.
This is where Information Technology comes in. The current generation of info-tech has produced vast data bases of medical records. Since this electronic information is so easy to manipulate and transmit, access and confidentiality are already an issue. Should health records be treated like credit reports and put on the Internet? Hopefully not. Strict laws are needed to keep organizations from discriminating against individuals whose potential health risks are not self- inflicted. Genetic predisposition is likely to replace race as the "Equal Opportunity" fairness issue of the 21st century.
Future advances in communication technology will create permanent and automatic links between health-care providers and their clients. You've probably heard about the beepers worn around the ankles of convicts under house arrest. They are tiny transmitters that track the individuals from a central location. Next, hook this device to a "smart" chip that holds an individual's health record and is kept in his or her possession. Once miniaturized, the chip can be embedded under a person's skin. The armed forces are experimenting with this concept now. Ultimately, the chip can be reconfigured to include sensors analogous to those that serve the diagnostic monitor station of modern car engines.
The benefits are obvious. Diabetics and their doctors could keep better control of blood sugar levels, while the various vital signs of heart patients could be tracked on a real-time basis. On the other hand, a healthy person might find the arrangement too intrusive if a Krispy Kreme donut sets off a "cholesterol alarm" or a shot of Jack Daniels triggers a "liver alert." While these examples may seem farfetched, future good health could exact a price in terms of privacy and self determination. Or would you rather live a life of abandon and let nature take its course? The choice is yours.
The next installment of this series examines options for living and loving in the 21st century Information Age.