A world without chronic diseases
Imagine a world without chronic diseases. How could they disappear?
We are now 20 years into the 21st century, one would assume that the causes of chronic diseases are understood and curable. Sadly, this is not the case. Most people believe that early prevention is the only means we have to fight these diseases. I don’t.
This essay is divided into four parts. In part I, I argue why treatment and not prevention will eradicate chronic diseases. In part II, I explain how digital precision medicine can play a part in said treatments. Part III describes the two building blocks of a digital precision medicine, target and time, and relates them to digital biomarkers and digital modes of action, respectively.
In the final remarks I highlight the fact that this essay is meant to provide a mental roadmap for steps we might take to find short-term opportunities. It is not a claim that we will cure chronic diseases like migraine in the near future — but we should also not rest until one day we have created a world without chronic diseases.
Part I: Treatment will not be an exception but the rule
It is said that prevention is better than treatment. This sounds reasonable. Only it isn’t. Human nature won’t work this way. Humanity will not eradicate chronic diseases by giving up key risk behaviors that can cause chronic diseases.
We would rather role the dice
Every single person has a certain predisposition to chronic diseases. There is, however, no direct link between unhealthy behavior and chronic diseases. Without this link, there is no inevitability. As a consequence, we would rather roll the dice, even if there is a good chance that it will not end well.
Given this optimism bias, the question is: How will chronic diseases disappear?
Digital technologies
What role will digital technologies play? If we are to still consider prevention, there are two possible approaches. First, we can try to address the optimism bias directly. A data-driven visualization of the actual risks might help override the human tendency of insufficient probabilistic thinking. However, it seems unlikely that it would be enough to completely overcome the natural denial of the risks some behaviors have to our health.
Second, we can try to advocate healthy behavior as an end in itself: digital technologies can support people to eat more healthy, engage in regular physical activity, and get enough sleep as a way of life. Still, eat, move, sleep, repeat—that just doesn’t sound like sufficiently satisfying human nature.
So, although chronic diseases are largely preventable diseases, we should stop focusing entirely on prevention and talk more about treatment. I’m convinced, treatment will never be an exception but the rule. While sustainable lifestyle change belongs to digital wellness (at least usually — I will be coming back to this later), treatment belongs to the emerging industry of digital health. To understand how digital health will play a central role in the treatment of chronic diseases we will look at a surprisingly simple new kind of precision medicine: a digital precision medicine.
Part II: Digital transformation strategy in the emerging industry of digital health
Any digital transformation strategy seems to be executed in three generic steps. It starts with information being moved from analog formats to digital formats. In health care, the converted information would be about the patient’s journey during diagnosis and treatment.
The second step is to streamline processes to improve operational efficiency. To distinguish this step from the first one, it is sometimes referred to as digitalization. Digitalization focuses on processing the digitized data to not only speed up the formerly analogue processes but to also improve data transparency. Of course health data can be misused. The fear of unauthorised secondary use is often hindering to the third step.
The third step unlocks new value by innovating existing products and services or developing completely new ones—also called from zero to one. In the health sector, this can happen in very different areas. One particular area is the innovation of precision medicine for chronic diseases that start early in life, such as migraine. A digital precision medicine would be a disruptive third step to the digital transformation of health care.
Unlearning chronic diseases: therapeutic rewiring
First let us clarify terms. Precision medicine means that the right patient gets the right treatment at the right time. Chronic diseases are lasting conditions with persistent or recurrent effects. Moreover, chronic diseases are usually idiopathic, meaning there is no known cause other than the enduring predisposition to the negative effects. Of course there is an origin. There can be a genetic predisposition and there is the above mentioned unhealthy behavior. However, there is no direct link from genes or unhealthy behavior to the outbreak of the chronic disease. This means that the actual origin is deeply hidden in the “learned” pathophysiological reflexes of the nervous system. Our brains are exposed to various environmental events such as sensory stimuli, nutrition, hormones, stress, or even medication and can therefore develop in very different ways. Brains have plasticity.
But if the brain has plasticity, there is also no reason to believe that by a therapeutic rewiring of the brain with the right interventions over time, chronic idiopathic diseases cannot be also unlearned again: that is, they can be cured.
The key success factors of therapeutic rewiring are based on the two concepts, “target” and “time” of precision medicine. When we think of a digital transformation strategy in medicine, these concepts must be taken into account already at the first step of digitization. Since the disruptive third step involves gathering the necessary information about the patient’s path during diagnosis and treatment, we must tie our future vision of a world without chronic diseases back to the present with an attempt to collect the right individual attributes in digital formats in order to personalize treatments.
Part III: Digital precision medicine
The target: Digital predictive biomarkers
Getting the “right” treatment to the “right” patient is the first basic principle of precision medicine. The assumption is that either the disease is not explained by a single origin (etiology), or patients have multiple morbidities, or both. In the case that a disease does not have a single etiology, the disease’s name is an umbrella term.
The boundaries of diseases can be arbitrary in other ways, too. Fashion, politics and profit all play a part in defining diseases as a pre-scientific concept, so much so that one might even ask the question: Do diseases really exist?
Notwithstanding, the treatment is right if it is precisely tailored to specific molecular, physiological, or anatomical targets of the disease’s etiology. We could also look in a completely different direction. Maybe microbial pathogens will be revealed as the causative target for some of these conditions transform some chronic diseases to infectious chronic and hence curable.
The patient is “right” if he or she belongs to a patient group selected or excluded depending on whether they respond to the therapy or not, respectively. Someone who is excluded might actually respond to the treatment but suffer form severe side effects more than others.
The old paradigm of precision medicine failed due to gene-environment interactions. Rectifying this failure by adding new so-called ‘omics data sources (see image) to develop digital companion diagnostics is one of the most important tasks in the digital transformation of healthcare.
A key data source used to identify the target etiology in umbrella diseases will come from the results of specialized topical tests. These tests need to be developed with some a priori knowledge of the chronic diseases. They will often comprise a temporal component, hence wearable health devices that can monitor individuals continuously in an ambulatory setting will be important.
The time: digital mode of action (DMOA)
Getting the right treatment at the right time is the second basic principle in precision medicine. A digital mode of action (DMOA) has to always answer two questions simultaneously: what intervention and when?
Time plays a particular crucial role in a certain group of chronic diseases. Namely the many chronic diseases with episodic manifestations (CDEM) where people are healthy over certain, often long, periods of time and only suffer from regular or irregular outbursts.
»Chronic disorders with episodic manifestations are characterized by attacks of clinical dysfunction with an enduring predisposition to attacks on an ongoing basis. Many common neurological and psychiatric disorders fit into this category including migraine, epilepsy, multiple sclerosis, stroke, sleep-wake disorders, addictive disorders, schizophrenia and depression. Most of these disorders begin early in life and often exhibit progressive, intractable forms that impose enormous public health burdens« (Source)
Given the early onset and thread of developing intractable forms of CDEM one might question the abovementioned statement that lifestyle change belongs to digital wellness and not digital health.
Special lifestyle change concepts for people already diagnosed with a CDEM belong clearly in the healthcare sector. Such concepts greatly benefit from a dynamic approach, that is, using information from dynamic network biomarkers (see box) on the probability of the imminent episode.
With reliable information of the probability, we can design a time-dependent behavioral change strategy, more precisely: a resilience-dependent hyposensitization strategy that allows for exposure to certain risks at times of high resilience to attacks to unlearn the condition. So we neither role the dice nor do patients completely avoid engaging in any high-risk activities. Improvement in health behavior does not necessarily lead to improvement in health status of patients with chronic diseases because this also could be the basis for a vicious cycle when sensitization may initiate an overexcitation of the affected physiological system.
A resilience-dependent hyposensitization is only one of many DMOA. DMOA are derived from the mathematical field of non-linear dynamics (a.k.a. chaos theory) and applied to periodic diseases, which will lead towards a new kind of digital chronotherapeutics and emerges from dynamical digital biomarkers.
A thought experiment, not a claim (Final remarks)
To imagine a world without chronic diseases is a thought experiment guiding the digital transformation strategy in chronic disease care. It is also a definite optimist seemingly new in biotech and medicine, as Peter Thiel argues, biotech startups are an extreme example of indefinite thinking.
Any digital transformation strategy starts with the first step of moving from analog to digital processes. The second step is to streamline these digital processes to improve operational efficiency. Only the third step unlocks new value innovating existing products and services or developing new ones.
Thinking from the end, one realizes that simply digitalizing behavioral therapy is not sufficient. For example, the typical 12-week smartphone-based generic programs of digital cognitive behavioral therapy can be effective and efficient. Instead of a licensed clinician, often lay coaches engage with the patient. With regard to the first two steps of a digital transformation strategy this seems all good.
Humans do not belong integrated into a digital mode of action
If one thinks from the end, however, one may conclude that biological clocks with long periods can play an important role for the large group of patients with a CDEM. In these cases, disease-specific smartphone-based lifelong chatbot coaches follow not only the true »Heroism of Incremental Care« but will also collect the critically important data for innovative new products based on new digital biomarkers. Allowing human coaches to be part of the behavioral therapy will actually be hindering innovation.
With the right data, we will indeed be moving much closer to our vision of a world without chronic diseases treated by pure DMOA — by mathematics that is.
Images
Header: https://www.piqsels.com/ CC0 1.0 Universal (CC0 1.0)
Public Domain Dedication
Binocular (inset ind figure): from Pixabay https://pixabay.com/illustrations/binoculars-tool-equipment-zoom-1940395/
Pills dispenser https://www.needpix.com/photo/463425/pills-dispenser-pills-medicine-organizer-tablets-medical-warfarin-digoxin-dispenser
