Posts Tagged ‘Medicine

20
Jan
11

the path to a new health paradigm takes one big step

Two or three years ago as the first direct-to-consumer DNA kits were being offered by companies like 23andMe and Navigenecs a big kerfuffle erupted when the California and New York departments of public health threatened to shut them down. The authorities claimed it was their duty to block the tests because the tests were offered online rather than through a licensed physician and because they were worried to death that the test results might be misinterpreted and cause unnecessary anxiety among recipients.

I was working with CA State Health Department people back at the time through my job in cancer public health. Nevertheless, I always suspected that the legal moves by the states were more to protect their statutory prerogatives and the medical profession than to protect the public. After all, I had been running into similar excuses to control cancer information among physicians for 30 years. Back in the ’70s some doctors would not tell their patients that they had been diagnosed with cancer for the ostensible reason that it would cause a lot of anxiety, and, besides, often there wasn’t much physicians could do about many cancers at the time. The situation improved after informed consent laws were passed forcing medical practitioners to explain diagnoses to patients before treating them. Also the organization I worked for would not give cancer patients professional-level pamphlets or journal reprints for fear of “confusing” patients and for fear of the docs who’d clobber us.

A lot of debate about the hypothesized impact of genetic information has been similar to the argument about the advisability of cancer information in years past. Fortunately some studies have been conducted to try to measure the emotional impact of genetic test information, especially genetic indicators for diseases like Alzheimer’s for which there is no treatment. The NY Times reported a couple of days ago about a study published recently in the News England Journal of Medicine that found essentially that news from the genetic tests didn’t cause a lot of anxiety in a study group of 2000. Many people didn’t take advantage of free genetic counseling offered or even discuss it with their doctors. Nor did the test affect behavior much in a positive way, such as changing lifestyle toward better eating habits. The surprising finding was how little impact the information had on people.

An author of one of the study stated:

“The medical field has been paternalistic about these tests,” says Peter J. Neumann, the lead author of the study, who is director of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center. “We’ve been saying that we shouldn’t give people this information because it might be wrong or we might worry them or we can’t do anything about it. But people tell us they want the information enough to pay for it.”

The author of the article, John Tierney, offers:

The traditional structure of American medicine gives control to doctors and to centralized regulators who make treatment decisions for everyone. These genetic tests represent a different philosophy, and point toward a possible future with people taking more charge of their own care and seeking treatments customized to their bodies. “What we have today is population medicine at the 30,000-foot level,” says Dr. Topol. “These tests are the beginning of a new way to individualize medicine. One of the most immediate benefits is being able to use the genetic knowledge to tweak the kind of drugs people take, like choosing among statins and beta blockers to minimize side effects.”

I agree with Tierney. This is a step toward a new way of medicine. As I write this the conflict over health care reform is on again. The health care model in the US is a mess and isn’t financially sustainable with about 8,000 baby boomers being added to Medicare each day. I think we need to shift a great deal of health responsibility to people, but it must be real, empowered responsibility with knowledge tools, decision making, and a support infrusturcture that’s available to all citizens. Conservatives use the term “responsibility” as a code word for blame. You know, “You’re  responsible (i.e., to blame) if you’re sick, not me. Don’t ask me for taxes to fix you up.”

If people are to take meaninful responsibility they need a system that provides them with meaninful information about their genetics, real time data about how they’re doing through, perhaps, mobile health monitoring, and a worldwide communication system that makes the latest scientific evidence about disease freely available in comprehensible, personalizable form. Putting up barriers to information like the results of DNA test through spurious fears of damaging effects is not the way to go about it. In the last century and a half we’ve created a huge, expensive scientific and medical system that restricts information and authority to an elite few gatekeepers. That’s got to change.

29
Jun
10

Uh-oh. In the minority…again

After my last post about the Australian scientist, Frank Fenner’s, apocalyptic prediction that humans would be extinct in 100 years — give or take a few — I decided to look around at how optimistic or pessimistic others are about the future. I didn’t have to look far. Today I ran across a survey by the Pew Research Center for People and the Press for Smithsonian.com about how optimistic Americans are about the next 40 years.

Well, Americans are plenty optimistic. The Pew summary starts: “Imagine a future in which cancer becomes a memory, ordinary people travel in space, and computers carry on conversations like humans.”

OK, I can do that! After all, I’ve been reading forecasts like that going back the the 1950s. Popular Science magazine did a lot of lists of what was going to happen and great drawings of people doing things like riding moving sidewalks. And, sure enough, 50 years later when I go to the airport there’s a moving sidewalk.

The other part of the survey intro is not so rosy, however: “Now imagine a darker future – a world beset by war, rising temperatures and energy shortages, one where the United States faces a terrorist attack with nuclear weapons.” Indeed, the survey is a mixture of up and down votes.

Many Americans see dramatic scientific and technological advancements on the horizon, with big developments in medicine, engineering, space travel and computers. However, despite the widely anticipated scientific breakthroughs – including the elimination of fossil fuels and gas-powered cars – the public foresees a  grim environmental future. Rising world temperatures, more polluted oceans and severe water shortages in the U.S. are seen as definite or probable over the next 40 years.

The survey is worth taking a look at. For my money, however, many of the questions frame the issues in such simplistic language that I wonder what people really intend with their limited answer choices. For instance, having been in the field of cancer public health for over 35 years I cringe when I see people were asked: “How likely do you think it is that…there will be a cure for cancer?” Seventy-one percent answered they thought definitely or probably cancer would be cured.

When I went to work for a cancer organization 36 years ago we had a slogan: “We’re going to wipe out cancer in your lifetime.” Today members of the cancer science and medical community are just happy that a sustained downward trend in cancer mortality is finally occurring. We stopped talking about “wiping out” cancer about 20 years ago. And oncologists are loath to even use the term “cure” when talking about outcomes for disseminated cancer. In fact, few people know it, but the goal of many in the cancer community these days is to make cancer predominantly a chronic disease rather than an acute, fatal disease. In other words success over the next few decades would be to enable the majority of patients with a wide range of cancer types to survive one or more bouts with the disease and die of something else. That’s a laudable goal, but it’s not anywhere near “wipe out.”

To think of cancer as one disease for which there will be a universal “cure” — that’s what the phrasing of the question implies — is kind of a throwback to the naive idea of several decades ago that cancer can be eradicated. It’s a basic misunderstanding of the disease. Unlike communicable disease, cancer is not something that attacks you from outside; it’s a malfunction of essential processes at the core of cellular life. I recall a breast cancer researcher who said every time a cell divides there’s a little risk of heading towards cancer.

Progress is being made these days, but the lengthy process of testing new approaches not to mention the enormous costs associated with recent cancer treatments means that there a huge obstacles besides the disease itself to having a big impact on the population. So, the last day I was in my office when I retired six months ago, I found myself reassuring some young staff who were just starting their careers that there would still be a big cancer problem for decades to come. In other words, they’re not going to have to change careers because a sudden “cure” arrives.

The Pew survey suggests to me that the public is finally adjusting to the reality that dealing with cancer will take much longer than anyone could imagine a few decades ago. The figure showing that in 2010 71% of respondents expecting a cure is down from 81% in 1999. A drop in the number of people expecting a cancer cure in the next 40 years may not be “pessimism” but a more realistic assessment of the situation instead.

I think people who have in-depth information about any of the questions asked in the Pew survey would have questions about interpreting what the answers mean. While surveys like this tend to suggest optimism is good and preferable to pessimism, the fact is that skepticism often reflects a grasp of reality.

Among the other opinions expressed by the survey group are:

  • In 40 years computers will converse like people.
  • Artificial limbs will work better than natural ones.
  • Most of our energy will not come from oil, coal and gas.
  • The world will get warmer.
  • We’ll have a major energy crisis.

These findings reflect the subjects’ attitudes and aspirations than they are an analysis of the future. Most of the challenges to be faced during the 21st century will be massive processes not seen in the history of the Earth. There’s really no precedent for the confluence of forces unfolding in our time.

One final thing. Forty-one percent of the respondents to the Pew survey expect Jesus Christ to return to Earth some time in the next forty years. That would make moot the dire speculation by Fenner that the human species will become extinct in the next 100 years wouldn’t it?

27
Mar
10

do patients need doctor navigators to use the internet?

In the March 25 New England Journal of Medicine Drs. Pamela Hartzband and Jerome Groopman of published an opinion piece titled “Untangling the Web — Patients, Doctors, and the Internet” in which they expressed a lot of concerns about how the internet is putting patients in touch with a lot of questionable information about disease and about how it is changing the doctor-patient relationship in an adverse way.

Since, overall, my views are about 180 degrees in the opposite direction, I’d like to quote some of their remarks and comment on them. (I recommend reading the full article so the context isn’t neglected.)

Information traditionally flowed from doctor to patient; the physician described the genesis and course of a disease and the options available for treating it. Often, pamphlets were provided to reinforce the doctor’s explanation and advice. The patient might then receive additional input from family and friends, usually in the form of anecdotes about people who faced similar clinical situations.

I can only say from my experience that the first sentence about information flowing from doctor to patient is pretty ideal. When I started working at the community level for a large national cancer organization in the ’70s there were doctors who not only didn’t explain the disease well but there were some who chose, on the basis of their judgement about the emotional frailty of the patient, not to tell some patients they had cancer. They’d tell a spouse or adult child perhaps. Fortunately, things have improved and, hopefully, the “don’t tell” practice has been replaced by informed consent. Still, I think for many situations the amount of information going to patients is limited by the short time allocated to face-to-face interaction with doctors. I am a Kaiser Permanente client. They have implemented email to doctors, online lab results, and an online information resource. The docs don’t give full explanations unless you press them on it.

Other patients whose diseases have no ready cure are drawn to chat rooms and Web sites that may make unsubstantiated claims — assertions that macrobiotic diets cure aggressive lymphoma, that AIDS can be treated with hyperbaric oxygen, that milk thistle remedies chronic hepatitis, and myriad other fallacious claims. Falsehoods are easily and rapidly propagated on the Internet: once you land on a site that asserts a false rumor as truth, hyperlinks direct you to further sites that reinforce the falsehood. Material is perceived as factual merely because it is on a computer screen. We sometimes find ourselves in the uncomfortable position of trying to dissuade desperate and vulnerable patients from believing false testimonials. Doctors may be perceived as closed-minded, dismissive, or ignorant of “novel therapies” when they challenge such Internet rumors.

Firstly, there is absolutely nothing new about charlatans and doctors who have been peddling snake oil and gimmick cures for generations. Again, when I went to work in cancer control my organization had a major effort to combat “quackery.” Many, many cancer patients were getting all kinds of bad advice and misinformation from naturalistic health magazines and other sources. (For a thorough tour of the quackery hall of infamy, see Dr. Steven Barnett’s site Quackwatch.) People by the thousands were going to clinics in Mexico for cancer treatments no responsible doctor would perform. This was rampant decades before the internet. There was an epic, nationwide legislative battle over Laetrile, the marketing name for amygdalin from apricot pits. Despite the best efforts of medical and public health organizations, especially in California, Laetrile production was legalized in 27 states . The arguments about “freedom of choice” from the ’70s seem to have echoed down the decades and have turned up again in the rhetoric against health reform, especially in the condemnation of  comparative effectiveness determination.

Secondly, even highly authoritative institutions have to change their tune once in a while. When I joined cancer public health in the ’70s the medical community almost universally rejected the idea that food and nutrition had anything to do with the prevention of cancer. People who talked about a relation between nutrition and cancer were sneered at and called the “fruits and nuts” crowd. Thirty-five years later as I approached retirement I had to chuckle inwardly many times about the current enthusiasm for the view that diet and nutrition are key to the prevention of much cancer. These days ya gotta eat your greens and grains!

Thirdly, doctors themselves are not always reliable sources of informaiton. That’s why we have second and sometimes third opinions. Drs. Hartzband and Groopman cite anecdotes about people who believe unsubstantiated information from the internet and suffer anxiety or waste doctors’ time. But I think most of us who have been around a few decades have our own fist full of stories from our own experiences or those of friends and acquaintances where doctors have failed to diagnose something or misdiagnosed situations, where lab tests have been wrong or complex treatments have been bolixed up in a hospital. I think the public knows all too well from well-publicized reports about medical errors by the Insyitutes of Medicine that the medical system itself is far from fault free. With regard to health it’s a risky world, even in the bosom of the medical establishment.

The article concludes:

As physicians, we are struggling to figure out how best to use this technology in the interests of our patients and ourselves. Although the Internet is reshaping the content of the conversation between doctor and patient, we believe the core relationship should not change. A relative recently asked us, “What can you possibly learn from your doctor that is not available on the Internet?” We suspect we’ll hear such radical sentiments increasingly in the future. Knowledge is said to be power, and some of the past imbalance of power between patient and doctor may be equalized. But information and knowledge do not equal wisdom, and it is too easy for nonexperts to take at face value statements made confidently by voices of authority. Physicians are in the best position to weigh information and advise patients, drawing on their understanding of available evidence as well as their training and experience. If anything, the wealth of information on the Internet will make such expertise and experience more essential. The doctor, in our view, will never be optional.

Uh, count me among the radicals. Let me say that the doctors are not totally negative about the internet, but their overall conclusion is that every patient should vet all their information through their physician. It sounds like they’re saying — like other professionsals who’ve had their domain disrupted by the internet — we’d all be better off if the internet went away and we could return to the status quo ante.

I’m just here to assert that that’s just not going to happen. The genie has been out of the jug for years and it’s not going back in. The Pew Internet and American Life Project has been documenting for years now the growing reliance of the public on the internet in health matters. Doctors just don’t seem to get it that there are needs that they’re just not satisfying. The use of digital media for health information and support is only going to increase, and rapidly.

My position is not that doctors are somehow unnecessary. However, I do believe that ordinary citizens are capable of knowing much more and doing much more about their own personal health and digital systems are an evolving platform for that. And after the so-called “health reform” slugfest we’ve been through I’m even more convinced that we all need to be more autonomous. We can’t continue to depend on a cabal of politicians, doctors, hospitals, insurance and pharmaceutical companies for our health. It’s just too important.

My suggestion to physicians is, instead of promoting a somewhat idealized notion of the doctor-patient relationship unsullied by the internet, why not work with citizens, professionals, and organizations to make the internet a better platform for the public and for doctors and patients to work together around their health issues? There are many support measures that can be undertaken. If docotors are worried about accurate information then why not build a comprehensive, evidence-based, easily accessible, user-friendly information resource? Medpedia, a project started by a consortium of medical and public health schools, is an interesting and constructive exercise along this line. Only thing is, the site is not public-friendly and so far the effort appears not to have attracted much involvement from anyone but professionals.

The concern about people not being able to critically evaluate health information is certainly legitimate. In fact, evaluating ALL internet information is an issue. But where is the support system for helping people learn how to do that? Why don’t doctors and organizations get busy spelling out some guidelines for evaluation and get them disseminated through many channels? That would be constructive and doable.

There already is a kind of parallel world of information and tools starting to envelope the health sector. (Tip: If you think the internet is something, check out the apps in the iPhone App Store supposedly intended for medical professionals but perfectly downloadable by anybody.) It’s like the way the blog-o-sphere enveloped journalism. After a lot of pining for their old, defunct newspapers, more far-thinking journalists have learned how to work with digital media and to reclaim their futures. Something similar is happening in medicine and, hopefully, perceptive medical professionals will learn how to work with it rather than try to will it away.

25
Mar
10

if they live into the 22nd century, what then?

I’ve mentioned before that the chance of children born now have a 50/50 chance of living to 100. Prof. James Vaupel of Duke U puts it this way:

“It is possible, if we continue to make progress in reducing mortality, that most children born since the year 2000 will live to see their 100th birthday — in the 22nd century,” Vaupel said. If gains in life expectancy continue to be made at the same pace as over the past two centuries, more than half of the children alive today in the developed world may see 100 candles on their birthday cake.

In my 40 years in public health the drive I saw in health institutions was to work relentlessly toward reduced mortality and greater longevity. That was without question our measure of success. I never heard anyone ask if there were any unintended consequences to all this effort or anything we might need to prepare for.

Fortunately Dr. Vaupel seems to signal a change.

This leads to an interesting set of policy questions, said Vaupel. What will these dramatically longer lifespans mean for social services, health care and the economy? Can the aging process be slowed down or delayed still further? And why do women continue to outlive men – outnumbering them 6 to 1 at age 100?

It also may be time to rethink how we structure our lives, Vaupel said. “If young people realize they might live past 100 and be in good shape to 90 or 95, it might make more sense to mix education, work and child-rearing across more years of life instead of devoting the first two decades exclusively to education, the next three or four decades to career and parenting, and the last four solely to leisure.”

One way to change life trajectories would be to allow younger people to work fewer hours, in exchange for staying in the workforce to a later age. “The 20th century was a century of the redistribution of wealth; the 21st century will probably be a century of the redistribution of work,” Vaupel said.

Good thinking!

22
Mar
10

Cancer costs breaking the bank?

Recent figures compiled by the Kaiser Foundation’s Medical News from a number of sources highlight how much the cost of cancer treatment has jumped in the last decade or so.

USA Today: “The cost of cancer treatment is ‘skyrocketing’ — both for individual patients and the nation, a new analysis shows. From 1990 to 2008, spending on cancer care soared to more than $90 billion from $27 billion. The increase was driven by the rising costs of sophisticated new drugs, robotic surgeries and radiation techniques, as well as the growing number of patients who are eligible to take them, says Peter Bach of New York’s Memorial Sloan-Kettering Cancer Cancer, co-author of an analysis in today’s Journal of the American Medical Association.

HealthDay News: “New chemotherapy agents for metastatic colon cancer improve patient survival but are costly, says a new study. Researchers at Emory University in Atlanta analyzed data from 4,665 patients, aged 66 and older, diagnosed with metastatic colon cancer between 1995 and 2005. Compared to those who received older chemotherapy agents, patients who received one or more of the six chemotherapy agents approved in the United States between 1996 and 2004 lived an average of 6.8 months longer. That increase in survival was associated with a lifetime cost increase of $37,100, which equates to $66,200 per year of life gained.”

As I’ve said before, one of the big surprises of my career in cancer public health was that cost would become as big a barrier to achieving reduction in cancer mortality as some of the characteristics of the disease itself. Between the early 1970s and maybe 2000 the cancer  control community never talked about cost. The advocacy organization I worked for kept focused on the rather idealistic goal of finding the cures for cancer and making them available regardless of the expense. That wasn’t seen as our concern.

Then the disparities in survival rates among ethnic groups began to show up, an indicator that is pretty closely associated with income. After that, the really expensive “targeted therapies” started to come out of the biotechnology companies. The shockingly high cost of rounds of treatment with the highly engineered molecules designed to disrupt specific cell growth “pathways” in cancer cells was a jaw-dropper. The first impulse was to condemn the biotech companies for greedy profiteering. I happened to be familiar with some of the main companies in the SF Bay Area, so I heard the other side of the story from them. I realized that it is not at all easy or cheap to pursue that way of dealing with cancer. I think we have to look at the drugs out there now as experimental drugs, almost research. There may be reason to hope that the technology for this will improve and drop in cost over time…but I wouldn’t bet the farm on it.

In the last year or so that I worked in the cancer community I began to say that — as an advocacy organization — we had a responsibility not only to push for progress on the disease but to develop recommendations as well for how to do it that took into consideration real-world issues like the overall cost. I doubt that many advocacy organizations in health have costed-out their goals in society-wide economic terms. I’m hoping that the rancor of the health insurance reform debate that is going on is also an eye-opener for nonprofit health organizations. Advocacy organizations tend to get tunnel vision. They need to step back and look at where their cause fits in the bigger picture of all the other needs.

16
Mar
10

Article: Remember the Tamagotchi?

In Wired News last week Thomas Goetz wrote an article about how — in the rapidly emerging world of sensors and self-monitoring — we may become something like the Tamagotchis kids wore a decade or so ago. The Tamagotchi (in case you’ve forgotten) was a little character on a watch face that you had to pay attention to during the day or it got sick and even died from neglect.

The new thing is to use the medical sensors that are being developed to get real-time information from your body and use it to give you a reading on how you’re doing. This could be constructive information for a variety of health situations. I referred in my post last week on things that need to be done for a new health paradigm as an avatar system. It could live on your smartphone, pick up sensor information from your body, compare it with your on-phone health profile, and tell you how you’re keeping up with health goals like exercise. It could feed you — or nag you — with appropriate health information. I agree with Goetz that a game interface may be the most interesting way to interface with some health informaiton.

This evening I’m attending the VLAB meeting at Stanford called “The Internet of Things: Sensors Everywhere.” I hope to get a better fix on where body sensor tech is and what we can expect in the near future.

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07
Mar
10

Health paradigm for the 21st C, part 2

Okay, Part 1 of this post was precipitated by the Society of Participatory Medicine’s request for ideas about what members would like to see them do. I talked about my take on the whys and wherefores of participatory medicine. This post is a list of eight activities I’d like to see supported by the Society for Participatory Medicine:

1. Develop an actionable plan for the goal of enabling each individual to become his or her own primary care authority for 90%-95% of health incidents.

Primary care docs want to go specialist because it pays more, so why not elevate the individual to the primary care provider and boost the physician to the role of spcecialist involved as needed? A few months ago during the health care debate on The Health Care Blog I saw a remark (by a physician, as I recall) that about 80% of health events are handled by the individual: cuts and minor trauma, headaches, colds and flu, aches and pains, nutrition, supplements, upset GI, menstral issuses, and on and on. The “drugstore” often the supply center for first-line of public treatment. What if that percentage could be elevated to with the right tools and support to 90% or 95%?

2. Develop a plan for building well-developed, well-funded information support systems specifically to support lifelong personalized health learning and decision making.

The internet is little more than a platform for informaiton storage and cheap distribution with content kluged together from unrelated sources.  However, people have already adopted the internet as a primary source for health information (Pew Internet Surveys). But so far there is no well-funded health resource base specifically designed to achieve anything like the goal above. The internet is a hodgepodge of sites and information of variable quality. WebMD and other commercial sites provide general content as part of their marketing platfrorm. Wikipedia is one crowd-sourced way to compile informaiton, but its quality has been challenged and the whole enterprise criticized. Medepedia, with content from academics from reputable institutions, arose pretty much to be an authoritative alternative to the noise of internet health information, but it’s primarily a reference work and does not seem to have figured out the public involvement part. There are thousands of nonprofit and government sites with bits and pieces of information, but there is no sign of a national commitment to an architecture designed to empower the public with knowledge in a person-specific or engaging way. The only site I am aware of that seems withing striking distance of the comprehensiveness of necessary is the National Library of Medicine.  Their Mediline and PubMed resources might be a precursor to a more innovative way of supporting personal medicine.

The information from a well-designed and well-networked system should contain a mechanism that helps everyone understand what medical information is “evidence-based” and what the certainty level  of current evidence is. The substantiation of information should be on a dynamic, constantly-updated basis. The system should also help people learn that scientific process works toward greater certainty over time and grey areas with less than 100% proof are a necessary part of understanding medicine.

3. The integrated health knowledge network suggested in iten 2 should take a systems approach to human biology and medicine.

In the 20th century the human organism was disassembled for study by segmentation and reductionism. Specialized areas of medicine, nonprofit organizations, and governmental expert agencies took off in their own directions too. The result is a very fragmented picture of health that still dominates today. Knowledge supporting personal health engagement should put the puzzle of health together. The knowledge base of health and life education should follow guidelines that support clarification of how various sub-systems of the human organism play a part in the function or malfunction of the whole.

4. The approach to participatory medicine should be founded on the principle that learning about health is a lifelong matter.

Information should be communicated and made available on an as-needed or just-in-time basis throughout life but within a cohesive systems framework. As I pointed out in an earlier post, parents are beginning to accumulate and electronically record information about children at birth. With the cost of full genome sequencing plummeting it is likely that the process will eventually become routine at birth. It does not seem out of the question that health knowledge can start at birth with a full family genome and health history as a basis for baseline health assessment and risk estimation.

From the outset, children are curious about their bodies and many teachable moments are possible if appropriate information is provided in a personalized, situation-specific way. A whole range of age-appropriate information should utilize current and future technology to find innovative ways of interfacing health information with many learning opportunities throughout life. Games, avatars, social networks, and virtual environments could be employed to engage various groups. People cannnot and need not become experts in all aspects of medicine, but over time they can become experts about themselves and the health matters that are issues for them as indicated by genomic data, family history, race and cultural variables. Needless to say, a health support information system will need to have as its mission staying abreast of and innovating with emerging technology.

5. Facilitate the evolution of an open sytem of quantifying sensors and devices that measure many aspects of bodily function, health status, fintess, and consumption that can be seamlessly integrated with the knowledge network, EHRs and informed by personalized health models.

The problem with life is that we are born without a “dashboard” for our bodies and with no operating manual. When health problems arise the symptoms such as pain, swelling, and other sensations are often too late to prevent acute illness. And our bodies provide few perceptible clues about the percursors of chronic conditions.

Health 2.0 activity has shown that there are many entrepreneurs eager to supply devices and services related to a personal approach to health. But technology standards committees need to be established or coordinated so that devices and data supporting participation can avoid what has happened in the electronic medical record industry. Interoperability and integration are essential, and the particpatory movement will be inhibited if these characteristics are not incorporated from the outset. Open data standards, open applications, and open media standards are necessary to put together the systems of communication, data recording and transmision, security, and social networking that are sub-systems of the greater vision.

The price of admission for entrepreneurs for participatory medicine should be open standards all around. Consumers should be advised not to support products that cannot be integrated with other components of the greater system (motto: “Homie don’t play ‘dat”). An encouraging development in this regard is the Open Mobile Health Exchange . Nevertheless, ongoing advocacy in needed to keep standards open.

6. Drive a counter-culture movement that encourages the US population to reset its expectations of the market economy from tollerance of the current state of health irresponsibility to one of health-benefit.

The market system in the US is health-indifferent; it is not accountable for focusing on consumer products that are designed to exploit basic cravings regardless on long-term personal or societal health burdens. In fact health corruption and health correction are complementary streams of income. Billions of dollars are spent on the design and marketing of products that contiribute to illness only to be answered by products and services marketed to compensate and bring us back toward health. It’s an amazing wealth engine where the right and left hands wash each other.

The weird thing about health “responsibility” in US society is that, with regard to food and drink, only consumers, not producers of goods, are considered responsible. If we over-consume a product designed and marketed to maximize our consumption, the producer is not held accountable. That’s the way it used to be with tabacco, but we changed the preception of responsibility about tobacco between the 1970s and the end of the last century.

A similar cultural change is needed about food and drink. We have a start;  producers of suggary cereals and high fructose corn syrup drinks have been criticized for marketing them to children. Similar accountability — or at least  social scorn — is necessary for other consumables. Producers have gotten away with saying, “Hey, we don’t force you to drik all that corn syrup. It’s your fault, not ours.” Perhaps as the extreme cost in dollars to US society from obesity and its consequences generates even more pain we’ll be less willing to swallow the denial of culpabiity that the marketplace hides behind.

7. Advocate for the funding developemntof human biological system models that can be personalized so that a constant stream of information may be analyzed and used as a source of near-real-time feedback about our health status and behavior.

We need sophsticated human systems biology and computer health models based to the best scientific information. They should be designed so that health data from our genomes, family history, lifetime health history, and from daily activity can be combined to form a personalized profile or algorithm. Our own model — embodied perhaps as an avatar — could be constantly available to interpret data and give us feedback or status reports. Such personalized models could also set the appropriately personal context for health information and learning.

8. Work to support augmented reality development for an environment that will enable us to get information on-the-fly about what our options are for the things we eat and drink.

Institutional support is needed to creating an augmented reality environment of information for restaurants and markets via databases that support easy access to informaiton about what we’re consuming. Bar codes, wi-fi, Bluetooth,  RFID tags  and new future technology should allow smartphones to immediately obtain information about the nutritional content of meals in restaurants and packaged products in markets. I already use an app called “FoodScanner” that uses the iPhone camera to scan package barcodes, look them up on a remote database, and provide me with the nutrition information food products are required to have on the package. The information can be saved for future use, but the whole process is pretty klutzy. A system that automatically grabs infomation and checks it against a personal profile of stuff to avoid is not hard to imagine.

When I was  in school at ~13-years-old we had “hygiene” class in which we had to learn the parts of the body (“pipes and plumbing,” as it was known) and their functions. Then in high school we boys got movies and slide shows with “the coach” to graphically show how disgusting VD and pregnancy are. That was supposed to deter us from sex until marriage. It was also  all I got from public education about health. I suppose it was somehow supposed to enable me to maintain my health for life.

The steps I outlined above is, I hope, a more robust approach and consistent with technology and lifestyles of the near future. The iGeneration evidently no longer sees a reason to fill their heads with generalized infomation with less that obvious personal applicability. They already know they have the option of getting appropriate information at the time it’s needed. Perhaps they’re already aware that the infomation they’ll be exposed to during their lives will be changing constantly. Making this situation lend itself to a healthier population is going to require many elements working together.

The things I’ve suggested also are simply ideas for a long-term process. If there’s one thing I’ve learned from a career in public health it is that change tends to be a lengthy, nonlinear process requiring tolerance for uncertainty and unexpected developments. Change is a career, not a project.

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