Elsevier supports Research!America and its efforts to increase awareness of the health and economic benefits of medical research and build a strong base of citizen support for more research and innovation. Each year, we participate in its National Health Research Forum, this year on the topic “Is a ‘Disease-Free’ World within Reach?” You can view a summary and transcript of the event from Research!America here. We asked panelist Dr. David Neal, Senior VP of Global Academic Research at Elsevier and Professor of Surgical Oncology at the University of Oxford, to tell us more.
What did you think of the event?
I thought it was a bold and imaginative event that pulled together a lot of very senior thought leaders and people from industry, academia and government. It was good because it tried to identify a number of focused areas where change could be made that would impact pretty quickly on people’s lives.
What are those areas?
I was aware of the opioid issue in the US but was quite shocked, actually, at the prevalence of this problem and how much of a priority it needs to be for policymakers. Addressing this is critical because we are talking about improving people’s health, and interventions through pain relief are an important part of that.
Panelists spoke pretty bluntly about the irresponsible prescribing of opiate drugs. For example, one described a common occurrence where someone has a dental extraction, and instead of being given a couple days’ treatment, they are prescribed 90 days’ treatment.
My point was: what knowledge do we have right now that if implemented would make a difference? Of particular interest to me is using that knowledge towards the social determinants of health. Those with poor diets, who tend to smoke, drink and be overweight — those are the groups developing diseases.
For example, a lack of exercise can aid Alzheimer’s and some of the causative effects of cancer. We’re aware of those, but what we don’t know yet is how to change people’s behavior. So there are things we know now that if effectively implemented could be a major step forward for the next generation. For example, reducing obesity in children would be a major step forward.
The problem is that people write up various guidelines and treatments, but they’re not effectively implemented because they’re divorced from the day-to-day activities of physicians’ workstreams.
Is this an area where Elsevier can assist?
I do think that’s an area we are affecting now, both by ourselves and in interactions with our society partners. We’re working with our clinical solutions business to translate these guidelines into actionable pathways through the electronic health record (EHR), and we think that can make a big difference. Along with that, our product development groups are thinking that rather than spending two or three years developing a product, we enter partnerships and use more iterative processes to get these guidelines into EHR systems more quickly.
You’re based in the UK and brought an outsider’s perspective to the US-based panel. What are some of the similarities and differences between the US and UK?
One of the striking things about the US healthcare system is that, at one extreme, it has the very best that modern healthcare can offer. It has the cutting-edge treatments, cutting-edge technology and the best academic health science centers, which have really made a difference to healthcare. So there’s a lot to admire. But the problem is that the US GDP expenditure on healthcare is so high at 18 percent, and when you look at how it compares with other countries in terms of population health outcomes, the answer is that it compares rather badly.
If I were a US policymaker looking at how we’re spending all this money while the population overall is not doing terribly well, particularly when you talk about the wide variability in the quality of care within the US, I’d want to know why. Recently, we read about problems with infestation with hookworms in Southern Alabama (hookworm is a parasitic disease thought to have disappeared in the US many years ago – see an article here). This comes down to public sanitation and public health, and it’s one of the things we look to the US to really get right.
But look, every healthcare system is facing challenges. The UK is spending approximately 8 percent of its GDP on healthcare, which is really low, and that is causing problems of its own. So I’m not suggesting one system is better than the other, but the wide variation of care in the US is an issue. But we’re all under pressure to restrain healthcare expenditure, and … we all have a problem with aging population and most of the money being spent on the final years of life, as against spending on quality of life. That’s a global problem. And the other global problem is that inflation in healthcare is running much higher than average inflation.
The panelists today all spoke of what’s going right and what’s going wrong. What would you say was the most discouraging thing you learned today – and the most encouraging?
What’s discouraging was the opioid issue, in particular that it seems to have been led by poor prescribing habits. So it seems like it was an avoidable problem.
The encouraging thing was the recognition that investment in research, and particularly maintaining a balance between basic science and the implementation of research findings in a healthcare environment, was found critical. I saw total unanimity on this among the panelists from industry, academia and the government representatives who make the funding decisions, so that was really encouraging.
Your panel took on the topic of a disease-free world head on. Is that just a good name for an event, or is there actually a possibility of a disease-free world?
I think (NIH Director) Francis Collins summed it up well when he said that, when you look at the risk of an individual dying, it's 100 percent. I think what he was getting at is that we’ll never reverse the environmental impact of damage to our DNA that occurs daily, which eventually accumulates sufficient change in cell metabolism so that we get things like Alzheimer’s or cancer or cardiac disease. And I don’t see in the future that we’ll ever prevent that from happening.
[pullquote align="alignright"]“The secret to life is to die young at the oldest possible age.” — Gary Reedy, CEO of the American Cancer Society, quoting Dr. LaSalle Leffal in a conversation they had 20 years ago[/pullquote]
So he’s right, but underpinning his quote is that longevity is a reality. If you look today at an average 60-year-old who’s going to live to perhaps 95, they’re going to spend maybe the last 10 years of their life with a chronic illness. So the question is: Can we extend that period of well-being longer so that chronic illness is shorter? Gary Reedy (panelist and CEO of the American Cancer Society) was spot-on when he said the secret is to die young at the oldest possible age. And I think that is achievable even by exploiting knowledge that we have now.
What are some things that are being done now to help with longevity?
One area is basic research, and understanding the hand of cards we’re dealt with at birth, our germline DNA, etc. – how those “cards” we are born with handle early interactions with the environment. Things like the body’s reaction to alcohol, exercise or a good diet in childhood, understanding how those interactions offer a real opportunity for prevention or partial prevention of diseases in later life.
The second is biomarkers, measuring things in blood and body fluids that actually predict things before they happen. Predicting then preventing diseases like Alzheimer’s, lung disease or neurological disorders like Parkinson’s disease from happening in early interventions.
The third thing is understanding the genetic changes that occur in cancers so we can precisely target treatments and prevention strategies in individuals. All of these are examples of precision medicine, where a better understanding of the individual is going to impact what we know about a disease and how a particular person is going to respond to treatments.
The panel talked about some of the negative implications of a disease-free world. One panelist said overpopulation. You raised an interesting ethical consideration as well. Can you elaborate?
Yes, we talked for a bit about gene editing, the CRISPR technology, for example, where we can now edit DNA very precisely and make changes. And this is great news for solving some horrible diseases that are caused by very small changes in the DNA. I’m thinking of things like Huntington’s disease, where you have individuals with a long, gradual onset period of dementia and loss of muscular movement in midlife, where you know that editing out those small changes in the DNA would have real positive benefit.
There’s consensus that these technologies can have a real positive benefit, but there are also ethical concerns. Say we’re talking about dwarfism or Asperger’s: are they a condition of disease or part of the spectrum of normal human life?
I think you have to be very wise to know where that divergence takes place. And what’s even more worrisome is, if you started interfering with it, would you impact evolution? So when I discussed the example of my grandson’s Asperger’s on the panel, I was saying that it’s probable that some mathematical and musical geniuses have some changes in their DNA that are typical with Asperger’s that help them recognize amazing patterns and come up with things that others can’t. So interfering with this sort of thing when we’re not “all knowing” people means there are genuine risks to humankind and continuing human evolution from all of this cutting-edge genomic manipulation.
Sounds like this could lead to governments picking winners and losers among diseases to solve. Do you see a concern with that?
Yes I think so, and I think it may be about whether studying a disease is a tractable problem (addressable using new technologies). For example, a lot of mental health problems may well be determined by alterations in neural signal pathways, etc., but they have not so far been tractable, though I think they may be in the coming years. Francis Collins said some of the brightest students are going into brain science and neural function because of the feeling there’s about to be a breakthrough in our understanding there.
When funding is provided by NIH, NRC and other big national research bodies, oftentimes it’s driven by the burden of disease. So if you look at the causes of death – cancer, neurological diseases and cardiovascular problems – they tend to get a lot of attention. Whereas less glamorous problems that affect the quality of life don’t get as much attention from funders – partly because they’re not tractable and partly because they don’t kill people.
Anything else you learned at the forum?
Yes, one thing that came out during the day is that the career structure for scientists is becoming a problem – particularly that “clinician scientist” doctors who do a lot of research are having to spend a lot more time on the clinical practice side. Institutional income is being driven by both the clinical practice side and the pursuit of grants, so doctors are having to do both whereas they used to be able to focus more on one side of that equation.
Another thing that became clear is the importance of learning from other countries. Multidisciplinary, multinational research is becoming more important.
And the final observation is that we should remember all parts of the globe; we can’t solve these problems by looking just at the developed world or just at the developing word. And related to that, a lot of health problems are geopolitical. Think of mass migrations caused by economic or environmental disasters and the impact of warfare – these are causing major problems in health but are not going to be properly addressed by medicine alone.