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The Challenge of Changing Health

A new landscape fraught with obstacles, risks and opportunities

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The Challenge

There is perhaps no global enterprise changing as rapidly and as radically as human health. Shakespeare’s The Tempest offers an apt metaphor, in which the spirit Ariel sings of a “sea change”—a dramatic and profound transformation. This idiom—while often overused, much like its 20th-century successor, “paradigm shift”—succinctly describes the massive upheaval and ever-shifting landscape of patient needs and demographics, innovation processes and regulatory environments. While the biopharma and health industries must address an expanding population and explosions of new diseases, they must also work to fill the void left from the crumbling of the blockbuster-based business model, and make sense of the vast array of new scientific breakthroughs and technologies. As with any challenge of this scope, successful solutions will demand teamwork, and this teamwork will require balancing the interests among a diverse group of stakeholders: patients, physicians, payers, policymakers and biopharmaceutical companies. More difficult still, this balance must reach around the world, as the business and science of health is increasingly a global concern. For example, evolving infectious diseases can now move rapidly between countries, raising the threat of a pandemic.

For today’s health challenges and tomorrow’s solutions, numbers tell many of the stories. The foundation needed to support a strong healthcare system, for example, depends on how many people it must accommodate. And perhaps even more important, the needed health infrastructure must be designed to adapt to a growing number of consumers. According to the U.S. Census Bureau, the world population doubled from 1959 to 1999— increasing from 3 to 6 billion in just 40 years. Although the growth rate is expected to slow, the bureau estimates that the world population will hit 9 billion by 2045. Even now, the sheer size of the world’s population creates a formidable healthcare challenge. With today’s population still under 7 billion and health systems already stretched beyond capacity in many parts of the world, what changes must be made to accommodate a world that will include roughly 30 percent more people?

Beyond building healthcare systems that can treat more people, there must also be accommodations for the changing collection of people, which will include a growing percentage of senior citizens. The United Nations’ “World Population Aging 2009” points out that people over 60 years old made up just 8 percent of the world’s population in 1950, but that percentage grew to 11 percent in 2009, and it is expected to reach 22 percent in 2050. So, in a century, the percentage of senior citizens will nearly triple.

Indeed, aging will change the needs of tomorrow’s healthcare, but other challenges are also emerging. For example, “HealthCast: The Customization of Diagnosis, Care and Cure”—a 2010 report from PricewaterhouseCoopers (PwC)—notes: “While aging is often cited as a key driver of health spending, there is a growing concern that spending is increasingly spurred by generations of children facing costly chronic disease.” To build this report, experts at PwC surveyed 3,500 consumers and conducted interviews with academics, government officials, pharmaceutical executives and others in more than 25 countries—from Argentina and Brazil to the UK and U.S. A key finding revealed that “[b]oth young and old consumers are developing chronic diseases in record numbers, leading to explosive growth in the consumption of resources that is driving up spending and creating liabilities for future generations.” For instance, the report points out that more than one fifth of Australians under the age of 16 have been diagnosed with asthma. In addition, the report indicates that Alzheimer’s disease in Australia is expected to increase by 50 percent from 2003 to 2023.

Changing demographics of disease also exist in other countries. For example, India Today reported on April 12, 2010, that “heart ailments have replaced communicable diseases as the biggest killer in rural and urban India.” Such changes will surely continue in India and other countries, especially for chronic diseases.

A Chain Reaction of Chronic Diseases

Part of the danger of chronic diseases comes from the fact that one can trigger another. For instance, the World Health Organization (WHO) reported that 400 million adults were obese in 2005. Moreover, WHO predicts that 700 million adults will be obese by 2015. In addition to concerns over obesity itself, this health condition contributes to other chronic diseases, notes WHO, including cardiovascular diseases and diabetes.

Cardiovascular diseases, including heart disease and stroke, already make up the number one cause of death globally. Data from WHO show that 17.1 million people around the world died of cardiovascular disease in 2004, making up 29 percent of the deaths that year. By 2030, WHO expects cardiovascular diseases to remain the leading cause of death, estimated to kill about 23 million people.

Diabetes, another obesity-related disease in many cases, is also expected to increase. WHO statistics showed that 171 million people suffered from diabetes in 2000, and the organization predicts that diabetes will kill 366 million in 2030. Perhaps even more astounding, WHO predicts that the countries with the most cases of diabetes in 2030 will be India and China, with 79 and 42 million cases, respectively—compared to 30 million expected cases in the U.S. by that time. In the past, few would have expected India and China to suffer from such a classically Western disease, but this sort of unexpected change is precisely what makes the future of health such a challenge.

“Given the breadth of diabetes around the world, treatments for this disease must improve,” says Christophe De Block, an endocrinologist at Antwerp University Hospital in Edegem, Belgium. “The artificial pancreas will replace continuous glucose monitoring and insulin pumps. For the cure of type 1 diabetes, though, the question is: will transplantation or the artificial pancreas win the race? The battle against type 2 diabetes will also depend on the use of incretin-based medicine for diabetes and obesity.”

Although the increases in chronic diseases will add substantial responsibility to the healthcare systems of virtually every government, these systems will also need to find ways to prevent and treat infectious diseases, which will continue to cause worldwide health problems. Malaria and tuberculosis (TB), for example, killed more than 850,000 and 1.8 million people, respectively, in 2008, according to data from WHO. Worse still, some infectious diseases are growing more difficult to treat in some regions. According to “2009 Update Tuberculosis Facts” from WHO, “In 2008…the highest rates of MDR [multidrug-resistant]-TB ever recorded, with peaks of up to 22% of new TB cases, were in some settings of the former Soviet Union. In the same region, 1 in 10 cases of MDR-TB is XDR [extremely drug-resistant]-TB.” In the latter cases, TB resists even second-line drugs.

To battle such drug-resistant forms of disease, countries must work together. As explained by Ram Sasisekharan, Edward Hood Taplin Professor of Health Sciences and Technology and Biological Engineering at the Massachusetts Institute of Technology in Cambridge, Mass., “Substantial changes in the way we live today and how medicines are being developed, manufactured and used present both risks and opportunities for tomorrow’s human health, due to globalization and changes in the global economic landscape.” He continues, “Tomorrow’s health will depend on the capacity for enhanced international exchanges of information and transparency, as well as a concerted effort to decrease the lead time from research findings to development and manufacturing of medicines. At the same time, the speed of technological innovation goes hand in hand with enhanced capacities to observe, track, treat and prevent disease.”

Sasisekharan points out that infectious diseases in particular pose a growing threat. “Increasingly, health challenges in a specific population or place can no longer be viewed and addressed in isolation,” he says. “This is especially true for infectious diseases, which will be a major threat due to this same globalization. The development of novel approaches to treat such diseases requires global partnerships, and the net benefits cannot be underestimated.” He concludes, “Much could be at stake if we are complacent about global human health.”

Exploding Spending

The list of what’s growing in healthcare must also include spending. WHO’s “The World Health Report 2008—Primary Health Care: Now More than Ever,” for instance, notes that the global health economy is growing faster than the gross domestic product (GDP). Furthermore, this report indicates that the global health economy grew by 8 percent in 2000 and 8.6 percent in 2005. As the report states, “In absolute terms, adjusted for inflation, this represents a 35% growth in the world’s expenditure on health over a five-year period.”

The economics of healthcare take up the most resources in the U.S. The Organisation for Economic Co-Operation and Development (OECD) showed in its “OECD Health Data 2009” that “[t]otal health spending accounted for 16.0% of GDP in the United States in 2007, by far the highest share in the OECD.” The closest highspending countries were France, Switzerland and Germany, which spent 11.0, 10.8 and 10.4 percent, respectively, of their GDPs on health. What is more, the average among OECD countries was just 8.9 percent. This report also indicated that the U.S. outspends all other OECD countries in total health spending per capita—$7,290 for the U.S. and $2,964 for the OECD average in 2007.

The question is: does more health spending lead to better health? According to the data, the answer is: not necessarily. First, the WHO’s 2008 report notes that spending generates some impact. It claims that every $100 per capita spent on health creates a 1.1 year increase in health-adjusted life expectancy (HALE). Nonetheless, the same spending can lead to a wide range in HALEs. For instance, Moldova and Haiti both spend $100–250 per capita but get HALEs of roughly 70 and 45, respectively. Second, the OECD’s 2009 report points out that most “OECD countries have enjoyed large gains in life expectancy over the past decades.” For example, life expectancy in Japan increased almost 15 years from 1960 to 2006, even though Japan spent only 8.1 percent of its GDP on health in 2007. By comparison, the high health spending in the U.S. only increased life expectancy by 8.2 years during the same period. At the other end of life’s spectrum, the infant mortality rate in the U.S. in 2006, notes the OECD report, was 6.7 deaths per 1,000 live births. On the other hand, Luxembourg, which spent only 7.3 percent of its GDP on health in 2007, had an infant mortality rate below three per 1,000 live births in 2006. So, some countries spend less on healthcare but get better outcomes.

Despite the high rates of spending around the world, many countries still need more healthcare workers. In PwC’s 2010 “HealthCast,” surveys of experts in a wide selection of countries reveal this finding: “Seventy percent of health leaders interviewed by PwC said their systems would be more efficient if they had more primary care physicians.” The report adds that 79 percent of the leaders also needed more nurses.

The needs for healthcare professionals, however, are not static, because they will depend on how an area changes. In Asia, says Anand Tharmaratnam, senior vice president and head of clinical development for Quintiles’ Asia-Pacific region, “The reality is that there will be more patients in oncology, psychiatry and neurology, and the region is still underserved in terms of healthcare professionals in those therapeutic areas.” Moreover, improving health in the face of changing challenges will require more than added professionals. For example, drug lags—years passing before some new compounds become available in some countries—show that regulatory bodies must also adapt. As Tharmaratnam explains, “Looking ahead, I expect greater regulatory harmonization across the region, which is needed to prevent drug lag and provide quicker access to medicines. I also expect more drugs coming out of innovation in Asia—developed with a focus on improved timelines and greater value—which will contribute to the Asian health landscape.”

Despite Tharmaratnam’s optimism, some reports show that healthcare is not always improving—even in high-spending countries like the U.S. For example, the “National Healthcare Quality Report, 2009” from the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) reported: “From 2004 to 2006, the rate of postoperative sepsis increased from 13.2 to 15.1 per 1,000 elective surgery discharges of adults age 18 and over.” Such hospital-created problems in the U.S. must be resolved and are certainly part of the mix in overall heath challenges of the future.

Despite differences in how countries administer healthcare, such as public versus private funding, the problems they face can be quite similar. For example, the UK’s nationally funded National Health Service (NHS) receives recommendations from the National Institute for Health and Clinical Excellence (NICE) about medication, treatments and procedures, as well as ways to improve health in general and prevent illness. Still, according to Sir Andrew Dillon, chief executive of NICE, the UK’s biggest health challenges are “very similar to those in the U.S. Our challenges encompass all of the characteristics of a developed Western economy: aging population, sedentary lifestyle, poor diet and all the related diseases, including obesity, cardiovascular disease and increasing cancers.”

Given the range of competing interests involved in healthcare, getting the best outcome depends on reaching a balance. “You have to start by being really honest about it,” says Dillon. “That honesty is that there’s a limit to how much can be spent, regardless of the kind of healthcare system—private, government-sponsored or mixed.” Given that starting point, a system should focus on things that make the most difference. “The key test on something new is: does it provide an improvement over what’s currently offered in terms of quality or length of life?” Dillon says. “Sometimes, we must make the very difficult decision of whether that additional benefit is something that the health system can afford.”

Taken in sum, these reports and metrics from around the world show that higher spending doesn’t always buy better health.

Tomorrow’s Technology

Although spending in the past has not always improved health around the world, many experts remain optimistic. “Tomorrow’s health will be determined by better medicines,” says Hans-Georg Eichler, senior medical officer at the European Medicines Agency in London. “Notwithstanding the dearth of important drugs coming to market in the past years, the longer-term future of drug development looks bright.”

Eichler believes that knowing more about the human body and disease will drive healthcare to better therapies. As he says, “There are between 5,000 and 10,000 known targets in the human body that could potentially be influenced by new medicines; only 500 of these are now exploited—merely the tip of the iceberg of the potential that human biology and basic sciences have to offer for improving health.”

Other experts, too, express optimism about technology’s promise. Nancy E. Oriol—dean for students at Harvard Medical School in Boston, Mass.—also expects great advances through a better understanding of disease. “Just as scientific discoveries about the cures for diseases changed history, so will the discoveries about the mechanisms of disease change our future,” she says.

In part, maybe in large part, advanced therapies of the near future will be better focused. For example, a concentration on individuals already drives patientcentricity, or a focus on specific patients, in healthcare. As Eichler notes, “Current experience shows that the benefit-risk of new drugs is not constant across patients. Personalized medicine will change that. Advances in genomics and other sciences are now enabling us to select the right patient for a given drug.” In fact, Eichler already sees that happening. “Since 2000, 36 new drugs for various cancers were authorized in the European Union; 10 of these can be considered personalized medicines—that is, more than one in four drugs,” he says. “The future of personalized medicine is here.” Later articles in this publication will explore how this aspect of patient-centricity, as well as patient empowerment, advances in diagnostics and payer expectations are already changing the pharmaceutical business.

Many believe that even more technologies can be honed and improved in more specialized ways. “Minimally invasive procedures that enable patients to return quickly to normal lives, targeted drug delivery designed to treat conditions at their points of origin, and enabling physicians to remotely monitor the health of their patients and avoid costly hospitalizations are all ways in which human health will improve,” says Stephen Oesterle, senior vice president, medicine and technology at Medtronic in Minneapolis, Minn.

Patients will also play an increasingly interactive role in healthcare. As Oesterle says, “Another factor determining tomorrow’s human health is finding simple and effective ways in which patients can better manage their own conditions.” For example, he says, “Today, type 1 diabetics are able to manage their disease with continuous glucose monitors that talk to insulin pumps and maintain steady blood sugar levels in the body. This closed-loop system to treat one chronic disease can and will be applied to other conditions, from heart failure to epilepsy, enabling patients to live healthier and more complete lives.”

Tomorrow’s technology, however, will also involve other changes, some of which might not be as obvious as improving medications and treatments. “I think two non-scientific forces will catalyze rapid growth and wide distribution of the important new scientific knowledge,” Oriol predicts. “One, global connectivity and consciousness will speed education, invention and access to both the miraculous and the mundane; two—inspired by the baby boomers—the desire for increased longevity will cause society to redirect its interests from a focus on medical science to a focus on health science.” She adds, “This new knowledge will not only help us maintain the health we were born with but prevent the diseases we can’t cure.”

Indeed, disease prevention has been crucial to healthcare in the past and will continue to be so in the future (see “The Power of Prevention”). For instance, Oesterle says, “Worldwide human health will be determined by advanced therapies designed to not just treat chronic conditions, but to stem the tide of disease entirely.” Improving prevention, though, will take teamwork.

Partnering for Public Health

Efforts toward prevention could start today. “To improve health in Asia,” says Tharmaratnam, “education and prevention need to be the big focus. As its economies evolve, we have the opportunity to drive change in behavior, lifestyle and eating habits.” He adds, “This will represent the biggest return on investment.”

In many respects, the healthcare community knows what to do to improve health through public projects. As Oriol explains, “The same factors that determine today’s health will determine tomorrow’s health: access to clean water, safe air, adequate food and society’s determination to practice healthy lifestyles.”

Despite that knowledge, lots of work remains to be done in public health. Current estimates from the United Nations, for instance, indicate that 884 million people lack access to safe drinking water. In addition, “Progress on Sanitation and Drinking Water”—a 2010 report from WHO and UNICEF—points out that 39 percent of the world’s population lacks adequate sanitation. Even with these large challenges, some numbers give reason for optimism. For instance, the WHO/UNICEF report says that only 67 percent of China’s population had access to safe water in 1990, but that number increased to 89 percent by 2010.

In looking ahead and thinking of ways to improve tomorrow’s health, Dillon of NICE says, “The things that could make the most difference to health tomorrow are not high-tech things from pharma or biotech, diagnostics or medical devices, although they are important and will make a big contribution.” He continues, “To make the really big gains in health, we must make investments in public-health interventions: improve diets, stimulate exercise, stop smoking. In 20 years, the benefits of those changes would far outweigh any new technology coming into the system.”

For both advances in public health and healthcare, groups around the world must combine their efforts—if for no other reason than that the health problems of one country can easily spread to another. Consequently, the challenges to improving today’s health and tomorrow’s cannot be solved in isolation. One country alone cannot solve all of the problems. Moreover, recent concerns over some infectious diseases, such as avian and swine flues, show the need for global teamwork. The question is: who will provide the leadership that tomorrow’s healthcare requires?

As Benjamin Mason Meier, assistant professor of global health policy at the University of North Carolina in Chapel Hill, says, “Without leadership in global health, it will not be possible to achieve any of our goals for a healthier tomorrow. Where once the World Health Organization reigned supreme over global health, the new world order has left us without a strong leader to coordinate international initiatives to prevent disease and promote health.”

Such coordination must be created. “In a rapidly globalizing world, linking the world in shared vulnerability, it is imperative that globalized health institutions rise to meet these challenges, to secure human rights and to guide international efforts for the public’s health,” Meier explains. “Global health governance is necessary—now more than ever. With the current proliferation of actors and norms leading to a distortion of global health priorities, the creation of modernized leadership institutions in global health policy—if even possible under the current international system—will determine the success of all our future efforts to reduce disability and death throughout the world.”

To be sure, the world’s health already faces a sea change, and predictions for tomorrow forecast even greater ordeals to be endured. By the numbers, the estimates and expectations, tomorrow’s healthcare obstacles loom ahead as seemingly insurmountable waves that cannot be avoided or deterred. Perhaps a combination of technologies—such as genomics, informatics, water purification and other infrastructure solutions—and, of course, teamwork—among patients, physicians, payers, policymakers and biopharmaceutical companies—can be arranged in just the right way to make tomorrow’s world healthy, perhaps even far healthier than today’s. With the right mindset and guidance, challenges always become opportunities.

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