Medical advances can exacerbate inequality

Rapid advances in medical technology are likely to revolutionise medical care but, paradoxically, could also exacerbate health inequality, researchers warn in an opinion piece published in the journal Science Translational Medicine

Poor health can lead to or amplify poverty. Poverty, in turn, can reduce access to healthcare and increase the risk of disease. Fortunately, remarkable progress in preventing and treating disease over the last century has enabled many people to escape this vicious cycle.

There has been a significant reduction in deaths from common infectious diseases, as well as substantial declines in mortality and morbidity from non-infectious conditions such as cardiovascular and chronic kidney disease. Child mortality has halved since 1990. In almost every country, average life expectancy has increased by at least 15 years since 1960.

More recently, unprecedented advances in genetics, nanotechnology, artificial intelligence, robotics and a wide range of digital technologies are daily changing the landscape of biomedicine.

It is anticipated that medical technologies will soon make big impacts particularly in cardiovascular disease and cancer. For example, a new class of drugs called PCSK9 inhibitors have been shown to help lower ‘bad’ low-density lipoprotein (LDL) cholesterol, and anti-cholesterol vaccines and gene silencing technologies are in also development.

Meanwhile, advances in precision medicine, including personalised immunotherapies based on genetic profiles of individual tumours, are beginning to profoundly alter cancer treatment.

It sounds great, and for the most part it is. However, in their new paper, Victor Dzau and Celynee Balatbat of the National Academy of Medicine in the US warn that many people could be left behind.

“Rapid technological advances will increase the pace of change, potentially aggravating divisions between winners and losers and widening social inequity,” they write.

Indeed, the benefits of medical progress – particularly those stemming from more expensive or more complex technologies – have not so far been distributed equally. Consequently, health inequality is already a significant problem.

For example, those medical advancements that target cardiovascular disease and cancer will have a much bigger impact on public health in middle to high income populations, where they are the biggest killers. But in low income countries respiratory and diarrheal diseases remain the overwhelming causes of mortality.

There are concerns that emerging technologies could also increase healthcare costs, say Dzau and Balatbat.

In recent decades, increases in the price of drugs, medical devices and hospitalisation have contributed to a substantial rise in health spending. Continuing on the current trajectory, global expenditure is expected to exceed US$18 trillion by 2040.

Mariana Arcaya at Massachusetts Institute of Technology and José Figueroa at Harvard University, both in the US, recently explained in the journal Health Affairs that personalised medicine “will likely deliver breakthroughs in clinical care that disproportionately benefit privileged groups”.

They say this is partly due to high costs limiting access for poorer patients, and also because racial and ethnic minorities tend to be underrepresented in the studies that underpin these technologies, so there is a risk the treatments may not be as effective for these groups.

Innovative technologies also require a skilled workforce to successfully implement them, say Dzau and Balatbat.

In other words, specialist skills are required for doctors and nurses to use novel stem cell techniques or coronary procedures, for pathologists to work with artificial intelligence, or for laboratory technicians to work with the latest robotics.

“The question here is not only what will be done by people and what will be done by machines but also what will be the man/machine combinations,” they note.

Plus, the costs and logistics of training can limit healthcare availability. For example, there is evidence that highly complex treatment regimes requiring more specialist support can amplify health inequalities between socioeconomic groups, while more simplified treatment regimes have the opposite effect.

To keep pace with technology, dedicated and sustained investment in education and continuous training is needed – but is not always possible.

Furthermore, reliable access to up-to-date information and communications technology is vital, write Dzau and Balatbat. This includes the ability to securely store increasingly large amounts of data. Thus, digital inequalities, including poor infrastructure and vulnerability to cyberattacks, can also influence health outcomes.

The authors say that Identifying the societal risks that come with new technologies can inform the development of policies regarding how new technologies are rolled out. The approach can also help rein in costs.

“Medical and technological breakthroughs will provide new tools and approaches that will transform health and health care,” they explain.

“It is important to ensure that emerging technologies are available to everyone, not just a select portion of society.

“The extent to which the benefits are maximised and the risks mitigated depends on the quality of governance – the policies, norms, standards and incentives that shape the development and deployment of these emerging technologies.”

As the Hippocratic Oath maintains, primum non nocere. First, do no harm.

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