COVID-19 has highlighted the cracks in our current healthcare systems, protocols, and policies. How can we address these vulnerabilities and what more can we look forward to in the years to come?
The emergence of a global pandemic has brought healthcare, research, and development to the forefront. With vaccines, anti-viral pills, and many more in the pipeline, the world is in a much better position than two years ago to deal with COVID-19. As the world transitions into a new normal, what does a post-pandemic future look like?
Last November, we attended the second Future of Healthcare Week (22 to 25 November 2021), where academics, healthcare providers, policymakers, scientists, and representatives from associations, industry and finance share their deliberations on the opportunities and challenges in the healthcare space.
How can we work together to promote innovation? How do we best empower patients to take ownership of their health? Can the public, private, and civil sectors across both health and information technology come together to build a unified system? Can regions in Asia pave the way in defining the future digital healthcare strategy across the health ecosystem?
In this article, we summarise some of the highlights from the Future of Healthcare week.
Lessons from COVID-19
In 2019, the World Health Organization published a report on global preparedness for health emergencies, highlighting that as the world continues to face an increasing number of infectious disease outbreaks, apart from the loss of life, all economies are vulnerable, and countries risk social chaos. It was a warning then that the threat of an infectious and lethal pandemic is very real. Fast forward two years later, we have witnessed the impact of COVID-19 and how it has exposed the world’s vulnerabilities to health threats. Despite that, there is a silver lining and that is how it has brought the world together and accelerated scientific progress – the fast development of viable vaccines, the continued flood of research on diagnostic testing and treatments, and the incorporation of digital technology to aid public health measures. What lessons have we learnt from this pandemic to prepare us for the next health crisis?
One problem the pandemic has highlighted was the widening gap between developed and developing countries. While vaccine development has seen remarkable advances, we failed to make much progress in equity and fairness. “On the one hand, we’re making 2 billion doses a month, on the other hand, 95 per cent of people in low-income countries have not received a single dose. So there’s something about making it, and maybe making it regionally, that we really have to work on in order to achieve a kind of equity that we have been talking about,” commented Dr. Jerome Kim, Director General, International Vaccine Institute. In a separate discussion, Owase Jeelani, Consultant Paediatric Neurosurgeon, Great Ormond Street Hospital also pointed out, “The biggest threat to global stability, to global health, is asymmetry. It’s the inequalities, be that in resources, be that in the effects of climate change, and if we don’t address those asymmetries, then we’re on for a decline.”
Another takeaway from the pandemic is realising how differential laws and policies between countries slowed down the process of supplying vaccines. While differences in regulations have hindered vaccine supply, over the past two years, communication and collaboration between the authorities and companies have improved greatly such that in the next health crisis, there are proper avenues and channels ready to facilitate faster distribution of medical supplies and medicines.
The pandemic had also exposed our digital deficiencies, making them more apparent than ever. How can we support home-based care and provide better diagnoses? These are things we have been considering before that have now been pushed to the forefront. As Fidah Alsagoff, Head of Life Sciences and Joint Head of Enterprise Development Group, Temasek has rightly observed, “In regard, while COVID-19 is an unmitigated tragedy in many senses, it also has been the moment of epiphany on what the potential is in digitalising our healthcare. When you shut down your face-to-face meetings, it really is the only way to do this. When we have no choice, we overwrite the massive amounts of inertia, finally all healthcare systems globally, without exceptions.”
Towards a Post-Pandemic Healthcare System
An EIU World Healthcare Outlook February 2021 report posits that the biggest opportunities in 2021 to 2025 will be in telehealth, diagnostics, nanotechnology, and cell and gene therapies; other analysts cite digital health and the localisation of supply chains as major trends. What can we look forward to in a post-pandemic future?
A More Holistic Approach to Clinical Pathways
Infection with COVID-19 has seen higher death rates among individuals with comorbidities. As we move towards patient-centricity in a post-pandemic world, how do we change research to treat patients with multiple illnesses? In an interview with Dr. Kieran Walsh, Clinical Director, British Medical Journal, he pointed out that much of our research these days are based around patient with single diseases. However, single diseases are becoming increasingly rare. “In the UK, 1 in 3 adults have multiple illnesses. Patients with multiple diseases are not included in trials. Then the results from the research will only work for patients with single disease. Older people have been excluded from trials as well. People of minority groups have also been excluded. All this needs to change to reflect what’s happening in clinical practice,” said Dr. Walsh.
To optimise treatment, there is a need for active collaboration and excellent communication between healthcare professionals to communicate not only amongst themselves but also with the patient. Providing a drug to manage one disease might make another chronic condition worse. “All these add up to a very complex knowledge base,” commented Dr. Walsh. Proper resources will have to be available at the point of care to support clinical decisions; it has to be accessible all the time, online or offline.
The population we are dealing with now is one with multiple conditions. These patients have an increased risk of complications, increased risk of a longer stay in the hospital, and increased risk of re-admission. All of which, adds up into poor quality of care and increased cost to treat those. Dr. Walsh pointed out, “There are cost-savings to be made in better management of patients with that, by enabling early discharge, preventing a prolonged stay, and preventing re-admission. It’s much better to get ahead of the game and prevent these complications from happening in the first place.”
How then do we get there? We will need a systemwide change in multiple streams of healthcare. Research needs to shift away from just focusing on single diseases. Guidelines and knowledge resources need to do better to give guidance to healthcare professionals to provide multiple care for patients with multiple diseases. Similarly, curricular programmes need to change so they can support healthcare professionals. Finally, the way healthcare is delivered needs to see more collaboration. Too much of it is from single healthcare professionals working in isolation, which just does not work; we will need generalists who can coordinate care.
Innovating Drug Discovery
In a separate conversation with Dr. Dean Ho, Provost’s Chair Professor and Director, Institute for Digital Medicine (WisDM), National University of Singapore, he shares that the latest innovations in drug discovery and clinical trials involve leveraging areas like digital and artificial intelligence to optimise treatments for patients.
He illustrated how patients who were previously not responding to the regular dosage of treatment start responding after the dosage was decreased. “Imagine the better quality of life, the fact that we’re acquiring valuable time for this patient off a different way of thinking about how we design a trial and leverage data to optimise treatment,” said Dr. Ho.
He shares about their platform known as CURATE.AI, where instead of defaulting to a standard dose for a patient, they calibrate the patient. As patients are different from each other and different from themselves over time, the “optimal” doses patients receive may not be the doses they need. With their platform, they can vary the doses within allowable ranges, measure their responses, and calibrate accordingly.
Such calibrated dosing is something we can expect in the near future as drugs become more patient-specific. However, more patient-specific drugs also meant the market for these drugs become smaller. Drug developers will have to develop more drugs for a smaller patient group. Dr. Nares Damrongchai, Chief Executive, Genepeutic Bio commented, “Companies would need to have multiple strategies and a certain degree of diversification and a very strong business model in order to manage the risks.”
Accelerating and Improving Efficiency of Care
Instead of the much-feared concern that technology will replace healthcare professionals, Kenneth Daniel Tan, President (Asia-Pacific, Japan, India) of Varian, believes that technology is meant to play an augmented role to support physicians and advance healthcare services.
“Technology is actually taking down that barrier in a tremendous way, and that’s happening in China. It’s not replacing the doctors, but enabling the doctors,” noted Ray Yang, Partner of Marathon Venture Partners.
For instance, now, there are technologies that can analyse CT scans in mere minutes, allowing physicians and surgeons to save hours of time usually spent to complete the same task. In dentistry, there are 3D printers that can create very precise models of the patients’ within just 10 minutes. Compared to weeks of traditional sample gathering and model preparation, such innovations have rapidly accelerated and improved the efficiency of care.
Decentralising and Democratising Medicine to Empower Patients
Technological breakthroughs such as digital therapeutics and wearable devices have also been democratising care by streamlining data collection and distribution. While traditional healthcare dynamics dictate that patients remain as passive “receivers” of care, patients of today are able to excise greater control and ownership over their health with the help of technology. For instance, diabetic patients can actively self-manage and monitor their own diet, exercise, lifestyle habits using wearable devices that relay information to their caregiver, which would allow real-time changes in treatment protocols. In doing so, these technologies are also helping to overcome the shortage of health equipment and workers as patients can resort to home-based care.
“[Technology] helps reduce the information asymmetry and the asymmetry of decision-making part that currently exists between the care provider and the care receiver. One of the reasons why healthcare is seen as a market failure is because the amount of knowledge that is concentrated on the provider who makes the decisions is far higher than that of the person receiving it. But with access to technology and information, and sharing of all the results - whatever assessments are going on - we can actually empower the person to also become a more active participant in the care decision making and also reduce the asymmetry and [that enables] a better system of health insurance and health coverage,” stated Ray Yang of Marathon Venture Partners.
Challenges of Innovating Healthcare Systems
When we compare the digitisation of the healthcare industry to other sectors like banking, travel, and retail, why is healthcare lagging 10 to 20 years behind? What are some challenges to innovating our healthcare systems?
Variability and Lack of Supportive Policies
Here, we heard from an anonymous panel of speakers from both public and private sectors who highlighted that the real reason behind the lack of innovation in healthcare is multifactorial. They pointed out that it is easier to bring innovation into banking because the end result can be quickly seen. However, the same cannot be said for healthcare as it is very diverse and complex. Innovation straddles various aspects of healthcare, for example, in drug development, digital technology or the infrastructure that we use.
A second reason they brought up is the severe funding limitations. While developed countries will fund research and development programmes, generally in most parts of the world, funding in healthcare development takes a backseat as they struggle to meet basic healthcare needs. Thirdly, regulation is stringent, which can cause some setback in development. Other things like adopting technology could also be so costly that people avoid investing in it.
Furthermore, a lack of supportive government policies can also be a hindrance. Though it is important to note that healthcare systems vary from country to country, any innovation will have to depend on the country’s government and acceptance of the digitalisation, and the healthcare system of that country.
Finally, the panelists also emphasised that innovation must be sensitive. Innovation in Asia would have to be slightly different as we differ from the rest of the world in terms of the prominent diseases we tackle here, social and cultural values, adaptability, etc. It is crucial that innovations within Asia be focused on the specific problems that we face in our region, and in the Asian regions, we have to acknowledge that the disparity between developed and developing countries is tremendous. While we may have big words like artificial intelligence, big data, and fancy innovations, sometimes it’s important to also focus on very simple cost-effective methods that would benefit the population.
Ensuring Affordability and Safety
One of the most heavily discussed topics in digital health, specifically telemedicine, revolves around cybersecurity. As pointed out by Lai Li Pang, Managing Director for Singapore and Malaysia of MSD, patients’ health records often contain not only health-related data but also highly detailed information of patients’ financial, socioeconomic, and demographic status. Therefore, it is crucial to set strict rules in place to ensure the protection of patient data and their privacy.
Besides data usage and privacy, Kenneth Mak, Director of Medical Services of the Ministry of Health, Singapore, also noted that there is a pressing need to improve the clarity and transparency on billing systems to promote value-based care and make digital care affordable. As we continue to integrate new technologies, it is crucial to ensure that healthcare remains affordable and safe.
K. Srinath Reddy, President of the Public Health Foundation of India, believes that simplifying devices and customising data sets required for specific purposes of care may allow for affordable technologies in primary care. According to Keren Priyadarshini, Regional Business Lead, worldwide health of Microsoft Asia, incoming non-healthcare players like R&D firms may also help bridge the gap between public and private hospitals and share the burden of innovation costs.
Clarifying Regulatory Frameworks
From a regulatory perspective, it is important to clarify the regulations and ethical considerations surrounding artificial intelligence (AI) and nascent technologies as they are quickly becoming the new care model. To do this, we need to clearly understand the current climate of healthcare digitisation in different countries and quickly set clear, robust policies to simplify approval and licensing procedures.
For instance, Sooman Kwon, President of Korea Health Industry Development Institute (KHIDI) stated there have been no official plans made to make telemedicine available to non-medical professionals due to administrative and technical barriers in incorporating telehealth to their national health insurance packages. Any service that is reimbursed by the health insurance must undergo assessments to set their value. However, it is difficult to set a value for services such as telemedicine and digital therapeutics. Likewise in Singapore, there are technical issues with the licensing of various telemedicine services, including but not limited to those that gather information without providing diagnoses, those that provide diagnoses, those that only act as communication platforms, and many more.
Future Challenges for the World Post-COVID
Tackling Non-Communicable Diseases with Gene Therapy
While COVID-19 has placed health at the forefront of our consciousness, it has diverted our focus from other potential diseases, particularly non-communicable diseases (NCDs) like cancer. With lockdowns and much of healthcare resources allocated to fighting COVID-19, there has been a major loss of opportunity for early detection and improved treatment outcomes for individuals at risk of NCDs.
While the consequences of delayed screening may not be apparent now, experts fear that there will be a post-pandemic “cancer surge” due to a backlog of cases. These problems, combined with the need to restore already fragile health systems, are expected to put healthcarein developing countries a decade back if we do not start acting on them now. But how and where do we begin?
According to Ruth Kuguru, Region Head, Engagement & Communications, Innovative Medicines of Novartis Pharmaceuticals, shining a spotlight on NCDs will require active collaboration and cooperation between healthcare consumers, healthcare professionals, the government, and pharmaceutical companies. Ellil Mathiyan Lakshmanan, Co-chair of SingHealth Patient Advocacy Network, believes that we need to spark a “conversation” between patients and caregivers to allow them “co-create solutions for the best healthcare outcomes.” Working closely with patients and key organisations, pharmaceutical companies must also help strengthen the healthcare infrastructure by innovating treatments, uniting patient organisations, and driving public-private partnership.
One promising treatment involves applying genetics to medicine. In recent years, there has been growing interest in therapeutic vaccines, cell and gene therapies for treating cancer, degenerative diseases, and immune disorders. Gene therapy involves introducing new genes into tumours or normal cells to eliminate or reduce tumour burden.
“Instead of treating the histology or the locations of the cancers, we’re treating the root genomic cause and that means researching treatment for one form of mutation, wherever that may be, has applications across a range of cancers,” said Richard Vines, Founder and Chairman of Rare Cancers Australia.
However, there are key challenges that still need to be addressed in precision oncology, including determining which cancers can best benefit from cell and gene therapies, integrating new therapeutic approaches more traditional approaches, and setting reasonable expectations for patients.
While cell and gene-based therapies like CAR T-cell therapy are effective in treating circulating blood cancers, they are less effective for solid cancers. In the specific case of breast cancer, Soo-Hwang Teo, Chief Scientific Officer, Cancer Research Malaysia revealed that “the mainstays for breast cancer remain surgery, chemotherapy, and radiotherapy.” Given that HER2-targeted therapy is comparably more effective in treating breast cancer compared to CAR T-cell therapy, Teo emphasised that these strategies should not be considered or used as a “magic bullet” across all different cancers and diseases, and that “we mustn’t throw out the old just because we’re jumping on to a new bandwagon.”
At the patients’ end, it is also crucial to set reasonable expectations for a cure.
“If you describe a targeted therapy as something that will attack the root cause of your cancer and inhibit it, then there’s a tendency to, almost immediately, for the patients, [to] jump to the word ‘cure,’ which is not the case because there may be delays, hurdles, and different outcomes as desired,” said Vines. The recent buzz on mRNA technology that is being used to combat SARS-CoV-2, has also raised great expectations of developing effective mRNA vaccines for cancer.
Joe Yang, Group Leader of the Institute of Molecular & Cell Biology, A*STAR Singapore, shared that EGFR-mutated lung cancers have been a good target for these mRNA vaccines. mRNA and peptide vaccines have also been very promising as an adjunctive to increase the immune response and build upon the existing immunotherapy tools.
However, cancer, by nature, is not a single disease, but rather one of multiple diseases. Treating different cancers will require different interventions. Therefore, Vines believes that we need to simultaneously boost health literacy to reasonably set patients’ expectations.
Additionally, Teo reminded that unlike COVID-19 vaccines that were quickly launched due to the urgency of the pandemic, vaccine trials and rollouts for cancers are unlikely to be performed as quickly since safety is generally prioritised over timeliness in NCDs. Moreover, translating the same technology to a completely different disease is an incredibly complex task.
“The challenge with cancer is that it’s not just about curing the cancer, but actually, it’s about curing the cancer without killing the patient because it’s due to genetic changes that take place in normal cells in that same human being,” added Teo.
Threat of Antimicrobial Resistance
One of the most concerning challenges that we see today is antimicrobial resistance (AMR). The current COVID-19 pandemic and the potential spread of antimicrobial-resistant pathogens are not much different from each other. Both spread far and quickly, affecting many people of any age (especially those with underlying conditions), in any economy.
The World Bank had estimated that AMR could cause around 3.8 per cent decrease in GDP by 2050. This is a significant decrease and puts pressure on humanity to figure out how to tackle that. However, unlike COVID-19, AMR is a crisis we have seen coming. To effectively deal with AMR, Pierre Gaudreault, President, Asia Region (Emerging Markets), Pfizer Biopharmaceuticals Group, Pfizer Inc. believes that coordination and collaboration is key. “[...] the world cannot tackle the growing spread of AMR without collaboration between every party – private, hospital, healthcare institutions, healthcare authorities, and all of the scientific community,” said Gaudreault.
He proposes a strategy with three major pillars to deal with AMR. 1) Surveillance – to make sure that we understand where resistance patterns and things are happening across the region so we can help the healthcare community. 2) Active stewardship – the element of making sure that the correct antibiotic is used for the right duration of time, and that there is an education and partnership between the industry and authorities. 3) Prevention – An element of prevention led by vaccines, where if we have more vaccines, we will see less infections, less antibiotic use, and less resistance in theory.
COVID-19 has pushed the bounds of human innovation and showed us what we can achieve when we work together, but it has also revealed what more needs to be done - addressing the current asymmetry,looking towards greater innovation in our healthcare systems, and how we approach non-communicable diseases. While COVID-19 is certainly not going to be the last pandemic, with the many research work in the pipeline and better collaboration between private and public sectors, theFuture of Healthcare Week has shown us that we will be in a better position to deal with it.