Health investment must adopt a more intensive upstream approach towards proven high-value interventions, and step away from its sci-fi fascination with the new, the expensive, and the unnecessary.
It’s a sunny Tuesday and i’m sitting in with a general practitioner who has just been handed a dozen-page scientific report by her patient. “You can see here, it’s tested all the important genes and tells you what diseases I am at risk of, and which medications are going to work for me and which ones aren’t.” The report from a private genomic testing service professes to examine the patient’s entire genetic profile and create percentage-point accurate estimations of everything from the risk of cardiovascular disease through to how the patient is likely to respond to individual medications ranging from warfarin to metoprolol. This specific report states that the patient is likely to require a higher dose of the anticoagulant warfarin than others, predicted due to her unique genetic composition. “I’m not really sure what to do with this right now” replied the GP, and in a perfect sentiment, had summed up what I imagine to be the entire profession’s response to the promise of personalised medicine that has been so prematurely laid fourth to anxious and cashed-up health consumers by the medico-industrial complex (1). Health is complex, but in our hastened rush towards reductionist, biochemistry-centric, science fiction-esque devices and technologies we have forgotten the basic building blocks of holistic and preventive care; the high-value upstream interventions that are the bedrock of population health (2). Although clearly attractive to some, personalised-dose rosuvastatin based on genome profiling should not be on the same playing field as such sensible evidence-based recommendations as to walk more and avoid processed foods.
Our patient here is far too well to be seeking out pills and potions for ailments she is yet to even experience, but this privileged position of the worried well is not universal. Often in healthcare patients that are seen are at points of deterioration of chronic illnesses, complications of grumbling poor health and lifestyles accumulating to a breaking point. These situations are regrettably common; the geriatric patient with orthostatic hypotension and falls, alcoholic now with liver failure, brittle asthmatic with another ICU admission, and diabetic with recurrent lower limb ulcers, are archetypal. There are certainly enough conditions for which their preventable, or at least manageable nature pushes any clinician to speculate what could have been done to prevent this at some stage earlier in the cascade. Such times are a necessary moment of sadness but from these examples we must look outwards to those patients yet to develop complications, at every stage of health, and consider how the pillars of primary, secondary, and tertiary prevention might best be leveraged. Health must be seen for every patient as more than a snapshot in time, but always as an opportunity to affect the trajectory of future wellbeing.
So we arrive at a model of health which considers that time opportunity for maximum value and maximum benefit for an intervention for any given our health issue. Such a model naturally illustrates how such upstream determinants of health represent both a common risk factor for many adverse health outcomes as well as an opportunity for cost-effective action with the potential to improve health trajectories over a lifetime (3). For the chronic non-communicable diseases over-represented in western society, almost any example can be traced in such a manner; from the adverse socioeconomic conditions, poor diet, and sedentary lifestyle through to the third cardiac stent in an atherosclerosis-laden coronary artery.
We need to increase our focus and funding of those traditionally soft enterprises of managing the social circumstances, proven community services that keep patients out of hospitals and manage health at early opportunities in a holistic and patient centred manner - funding longer GP consultations that focus on preventive care (4), linking patients to social workers, occupational therapists, population-wide access to dentists for early preventative care (5), early childhood services, safe emergency shelter and social housing, and youth employment services (7, 8). This isn’t especially revolutionary or idealistic utopian daydreaming, and social housing programmes have already demonstrated both real-world viability and tangible, immediate cost-savings, in the region of $13,273 saved for every $6,462 spent per person year(6). The more distal and intangible health benefits that accrue over a lifetime for individuals who receive such early preventive care are far more challenging to quantify, and even for well researched single-item health interventions, mortality benefit estimates vary considerably (7). Attaching a numeric figure to the benefit of a preventive care activity such as increased access to social workers is unlikely to be accurate or reliable, but this uncertainty betrays how worthwhile such investment is likely to be (8).
The value of public health domain preventative activities such as vaccination and smoking cessation programmes are almost universally recognised as economically worthwhile health investments, both examples further enhanced in the public mind by their underpinning mechanistic biomedical narrative; ‘exposure to a an attenuated pathogen primes the immune system to fight a burlier version later on’. The ongoing push to decrease smoking and increase vaccination rates is a noble enterprise but we should not be limited to consider only hard science approaches to primary prevention. Although mental health has garnered increasing attention in recent years as an undervalued and underfunded aspect in any holistic picture of health (9, 10), potential health and societal benefits from primary and secondary prevention in mental health represents a domain for which we seem to have only scratched the surface. From a clinical perspective, poor mental health often appears as a lurking factor in the relationship between poor health and poor medical care, preventing individuals from taking charge of their health. It’s hard to schedule a dentist checkup or book that blood test when you can’t find the motivation to get out of bed, or knowing you’ll experience a panic attack in a GP’s noisy waiting room. And the effects of poor mental health are seen down the line, as the progression of the trivial into the life-changing due to loss to follow up; and the occurrences of the entirely preventable disease due to self-neglect. Again, mental health is the underlying, but organic medical ailments are the symptom.
To realise the capacity for change in the entire trajectory of patient health at a population level will require concurrent investment in both the traditional, tangible, biomedical alongside the overlooked, softer, social welfare and mental health domains. Science fiction technology will never substitute the basic building blocks of health; equitable access to primary care, social supports, safe housing and food supplies…; and it is a truth that health systems seem painfully reluctant to concede.
T Michniewicz, August 2019
Reference
1. Maughan, T (2017) ‘The promise and the hype of ‘personalised medicine’"‘. The New Bioethics. 23(1): 13-20. doi:10.1080/20502877.2017.1314886.
2. Masters, R, Anwar, E, Collins, B, Cookson, R, Capewell, S (2017) ‘Return on investment of public health interventions: a systematic review’. Journal of Epidemiology and Community Health. 71(1): 827-834. doi:10.1136/jech-2016-208141.
3. Gehlert, S, Sohmer, D, Sacks, T, Mininger, C, McClintock, M, Olopade, O (2008) ‘Targeting health disparities: a model linking upstream determinants to downstream interventions’. Health Affairs. 27(2):339-349. doi:10.1377/hlthaff.27.2.339.
4. Sim, M and Khong, E (2006) ‘Prevention - building on routine clinical practice’. Australian Family Physician. 35(1): 12-15. Available from: <https://www.racgp.org.au/afpbackissues/2006/200601/200601sim.pdf> [Accessed: 03/08/2019].
5. Mouradian, W, Wehr, E, Crall, J (2000) ‘Disparities in children’s oral health and access to dental care’. JAMA. 284(20):2625-2631. doi:10.1001/jama.284.20.2625.
6. Wood, L, Flatau, P, Zaretzky, K, Foster, S, Vallesi, S, Miscenko, D (2016) ‘What are the health, social and economic benefits of providing public housing and support to formerly homeless people?’. Australian Housing and Urban Research Institute. Melbourne, Australia. doi:10.18408/ahuri-8202801. Available from: <https://www.csi.edu.au/media/uploads/AHURI_Final_Report_No265_What-are-the-health-social-and-economic-benefi..._2edQIWr.pdf> [Accessed: 03/08/2019].
7. Ewald, B, Mar, C and Hoffmann, T (2018) ‘QUantifying the benefits and harms of various preventive health activities’. Australian Journal of General Practice. 47(12). Available from: <https://www1.racgp.org.au/ajgp/2018/december/quantifying-the-benefits-of-preventive-health> [Accessed: 03/08/2019].
8. Shrank, W, Keyser, D and Lovelace, J (2018) ‘Redistributing investment in health and social services - the evolving role of managed care’. JAMA. 320(21):2197-2198. doi:10.1001/jama.2018.1498.
9. Australian Institute of Health and Welfare (2019) ‘Mental health services in Australia’ [online]. Available from: <https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services> [Accessed: 04/08/2019].
10. Sparrow, A (2018) ‘Mental health services get £2bn funding boost in budget’. The Guardian. Available from: <https://www.theguardian.com/uk-news/2018/oct/28/mental-health-services-to-get-2bn-funding-boost-in-budget> [Accessed: 04/08/2019].
