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Darwin's Medicine blog

Professor Brian D Smith is an authority on the pharmaceutical industry and works at SDA Bocconi University and Hertfordshire Business School.

In sickness and in health

If prevention is better than cure, we will need to help it along

It is a truth universally acknowledged, to steal from Jane Austen, that while we talk about healthcare, most of what happens is better described as sick-care.

Although we’ve known for decades that prevention is cheaper than cure, and that early cures are far better than later remedies, treatment still consumes far more of our spending than prophylaxis.

But my reading of the market is that this really is beginning to change. As ever, let me get to a practical conclusion via a diversion into the management science.

Paradigm shifts

When I’m asked by pharma or medtech companies to help them predict and prepare for the future, the biggest issue I face is that we’re often looking at the world from very different perspectives. In many companies, the executives I work with have very strong science and medical training.

That’s where I started my career too, in R&D, but I’ve been lucky enough to also have a social science training. The result of these different intellectual backgrounds is that we sometimes operate different paradigms, that is, different ways of looking at the world.

I often find that science-trained executives have a strong reductionist paradigm. Their habit is to reduce complex phenomena to a few constituents and to look for direct causal linkages between them. For example, demographics is causing an epidemiological shift, which is leading to constraints on market access.

I always have to weigh my words carefully when I reply. It’s not that their view of the world is wrong, I tell them. It’s just that it’s incomplete and overly simplistic. I can show them long papers or book chapters on the ‘value shift’ that has changed market access but even that isn’t the whole story.

I often end up relating my own paradigmatic journey, from reductionist and ‘logical positivist’ research chemist to being a pragmatist (in the special, epistemological sense) and looking at the world through the lens of complexity theory and Darwinian evolution.

Hamlet’s famous words, about there being more things in heaven and earth than are dreamt of in your philosophy, often rattle in the depths of my brain.

Emerging futures

What does all this philosophical, paradigmatic waffle have to do with sick-care transforming into something that deserves the name healthcare? Well, whatever your perspective, we all agree that preventative and early- treatment measures would be good for us all and that it’s frustratingly perplexing that they seem to be so slow in becoming the new norm.

And if you’re a reductionist, it’s very easy to find simple explanations for such a slow progression. Perhaps it’s the reluctance of payers to reimburse. Perhaps the technology isn’t right yet. Perhaps the market isn’t ready. All good, straightforward, reductionist answers.

And all correct but all incomplete and overly simplistic. From an evolutionary point of view, the future hasn’t emerged yet because payers, technology, patients and many other factors haven’t yet combined to create the selection pressures that favour prevention and prediction.

Here it comes

But you don’t have to look too far to see the future emerging. I’ve enjoyed reading recently about Withing’s new patient-use device that combines ECG, blood pressure and digital stethoscope with surprising accuracy. Even more interesting was seeing recent surveys that physicians are starting to take these home results seriously.

Complementing these patient- use devices, direct-to-consumer blood testing is gradually emerging too, along with self- administered tests for STIs, infertility and other conditions. Continuous glucose monitoring has transformed diabetes care in recent years and I’d guess it’s only a matter of time before we

see patient versions of Abbott’s i-STAT device. Out of the home, innovations like Philip’s Ingenia are enabling early cancer detection by integrating MRI and CT scans, which of course is increasingly complemented with biomarker technologies, like Illumina’s Trusight. In structural heart disease, long an under-treated condition, AI is being used by Edward’s Egnite to interpret ECGs for better, earlier detection.

Emergence, not causation

If, as I hope, we are finally moving closer to predictive and preventative healthcare, then how do we accelerate that trend? I’d argue that reductionist solutions, such as trying to convince payers to reimburse, are incomplete answers.

We need to understand the combination of conditions – economic, sociological, technological and others – that have to come together to make it happen. Abbott’s work, encouraging diabetes patients to be proactive in managing their glucose levels, is a good example of this.

And, as we know from Google search data, there is a large part of society that is ready and waiting to become obsessed with their own health data. Health technology assessors will need to be encouraged to evaluate whole systems and how they promote health and not, as they do now, assess how individual products manage illness.

Pushing the trend revealed by the surveys, we will need to reassure professionals that home data is not synonymous with bad data. Most of all though, we in the industry will need to start shifting the way we think.

No single factor will cause the future to happen but we can nudge, coax and persuade healthcare to emerge from sick care.

Professor Brian D Smith works at SDA Bocconi and the University of Hertfordshire. He is a world-recognised authority on the evolution of the life sciences industry and welcomes questions at

20th April 2021

From: Healthcare


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