Individual Health from Public Care

by Harald Siem

Harald Siem (Norwegian, born 1941) is a medical doctor with a master’s in public health, trained in Basel, Oxford, Oslo, and Harvard. He has worked as a district medical officer then at the University of Oslo, and for the Oslo city health administration, International Organization for Migration, and WHO in Geneva, and now works in the Norwegian Directorate of Health.

It might seem foolhardy to try to forecast the development in health and medicine in forty years to come. Looking back explains why. Unpredictable discoveries changed medicine.

Just one hundred years ago, there were hardly any really effective interventions in medical practice. Granted, we had caregivers and surgeons, and chloroform and ether had been known for fifty years. But modern anesthesia didn’t arrive until the 1940s. X-ray imaging emerged in 1901. Later came contrast angiography, then computerised imaging, followed by ever more advanced methods of making pictures of the human interior. The last forty years have brought spectacular progress, in the real sense of the word.

The medical armamentarium has advanced from bloodletting, enemas, and leeches to antibiotics, effective drugs, and other treatments against mental illness, heart disease, certain cancers, parkinsonism, and unwanted pregnancies. Heart transplantation was considered impossible when I graduated from medical school; today it is routine.

This wave of new effective treatments gave a boost to the status of physicians, who were increasingly let in not through the kitchen, but through the front door. But then patients rights started to constrain the physician. And medical ethics started its move from paternalism to consumerism.

Emerging Trends in Medicine

Technological gains will continue, and two areas are moving especially fast. One is the growing use of stem cells. These undifferentiated, pluripotent cells have the ability to change, or develop, into any one of the 200-odd types of cell that compose the human body—meaning they can grow into different kinds of tissue and possibly repair damage. The other is the use of genetically tailored medicines—drugs that alter, or compensate for, defunct genes. Both areas will see huge advance in forty years.

A number of infectious diseases will be eradicated. Likely candidates are polio, measles, encephalitis, a couple of worm diseases, and possibly AIDS. At the same time, it is likely that new strains of influenza virus will evolve, and that new communicable diseases will emerge, often from animal reservoirs. Road accidents will be reduced; mental illness and violence in close relations will increase.

As a consequence the disease burden of future populations will change. The industrialized countries will lead the way, but the trend is global. The health challenge in the future will be primarily chronic, lifestyle-related diseases. Obesity, diabetes, and Alzheimer’s disease will dominate the hospital wards and the nursing homes, first in the rich and later in the poor, or not so poor, countries. In the transition, some rapidly developing countries may have to live with the double burden of infectious diseases and chronic ailments.

The shift in the disease burden will force a shift in medical practice. Traditional practice was tailored for episodic illness—like pneumonia or appendicitis—where the patients perceived symptoms, the doctor diagnosed and treated the illness, and that was it. The chronic ailments require a different approach. They require a longitudinal organisation of medical care, where the patient is being followed over time—also before she or he turns ill. Health-service providers will encourage people to monitor and manage their own health.

As people become more affluent, they will have fewer children, consume less tobacco and less fat, and have more time for leisure activities. This again will shift the disease burden. And so will climate change, most directly through extreme weather, disease vector increase (or change), and coastal flooding and forced migration.

Medical intervention will become even more effective, and life expectancy will grow rapidly, adding a year every five years in most countries. Few countries will have a life expectancy of less than sixty years in 2052, and many will be as high as ninety years. The exceptions will be countries that have been severely hit by AIDS, former communist states in transition, and failed states. Exceptions may arise from a devastating flu pandemic or similar catastrophic setback. Better nutrition, education, and living conditions and safe environments will account for much of the progress where it occurs. Maternal and child health and vaccinations will also play an important role.

So in general there will be progress on a broad front. The high burden of chronic ailments needing long-term care will usher in computerized care programs and monitoring. Automatic sensors and computerized lifestyle coaches will modify behavior and manage illnesses like diabetes. Such programs will dominate medical practice in 2052 but will meet much resistance. The clinical freedom of practitioners will be under attack; the growth of bureaucratic medicine will be resented. On the other hand, concerns about quality of care and liability will ensure that programmed care adopts the latest of best practices faster than any single doctor.

Rising Medical Costs

So expenditures for health care in all societies will rise. One might ask whether there is a ceiling beyond which spending for health cannot grow because of the needs in other sectors of society. If so, it is not yet easy to discern: in the United States, residents spend 18% of the GDP for health care. It is simpler to predict that there will be limits for tax-financed national health expenditure. Most likely, the public coverage will be supplemented with private health expenditure, where individuals use their own funds to buy additional health services.

So there will be a development toward universal health coverage, even in today’s poor countries. The coverage can take two forms: national (tax-based) health systems or compulsory insurance schemes. Since medical needs for an individual arise in unpredictable ways, there is a logic for pooling risks, which means third-party payment at the point of consumption of treatment and care. But in all cases, the coverage will have to be limited in some way, in order not to bankrupt the system. The system will not be able to cover any condition or treatment. Costly treatment will be counted out, after bitter discussions of priority. One will not be able to avoid the question of who shall live. In other words, one will agree on what will be covered by a collective system, and what must be paid for by personal funds.

There are three competing forces in health: the demand from patients and patients’ organizations, the interest of health-sector staff and professions, and the need for cost control by the authorities or the insurance companies, representing the common purse. Health politics will remain about patients, providers, and payment.

So, by 2052, we will see life expectancy grow in most, if not all, regions of the world. We will also see infectious diseases decline and chronic diseases increase, along with our reliance on automated care. And there will have been a partial answer to the question of who must use his or her private funds to live.