What will health and medicine be like in 2032? University of Tartu Professor of Medical Microbiology and Virology Irja Lutsar, Professor of Biotechnology and Director of the Estonian Gene Bank Andres Metspalu, Professor of Psychophysiology Jaanus Harro, Professor of Pathological Physiology Sulev Kõks and Associate Professor of Andrology Margus Punab shared their thoughts.
In 2032, Estonia will be home to slightly over 1.1 million people. What will healthcare and the medical profession in Estonia be like at this time?
Lutsar: Medicine will depend on how many taxpayers there are. If Estonia’s population trend remains below replacement rate, much will depend on the government’s immigration policy. If nothing changes in this regard, we’ll have many people over 60 who’ll inevitably be healthcare sector clients.
But import foreign labour, and these will be younger people who lack the health problems experienced by the elderly. They will need maternity care instead, for example.
Punab: Empathetic doctors will be the biggest deficit item in 2032.
Harro: Already now we’re in a situation where applying cutting-edge medical technologies to meet our needs would take up all of the GDP and then some.
We have a range of technologies that we consider essential and beneficial. It will take up our entire healthcare budget. Basically, we need to reconsider what is reasonable. It’s likely that in 2032, many things that we still consider reasonable now will no longer be seen that way. We’ll be forced to reappraise cost-effectiveness. We currently want longer life for everyone at all cost. At some point, though, we’ll probably need slightly more specific priorities.
Lutsar: Another important issue is regional policy. When a big percentage of Estonians live in Tallinn and within a 20 km radius of Tallinn, it’s clear no one will travel 180 km away (to Tartu) if they’re acutely ill.
And I’m not just talking about whether there will still be a hospital in Võru or Põlva. I’m talking about Tartu University Hospital. We will likely need an agreement in Estonian medicine that Tartu and Tallinn should not provide overlapping services when it comes to specialized kinds of surgeries, kidney replacement therapy and organ transplants. The pre-clinical side of studies depends on how good our biologists, chemists and physicists are. As to the clinical side, we need patients. We probably need an Estonian medical school and clinical studies will have to move to Tallinn as well.
Punab: Germany has a number of relatively small cities like Heidelberg with top-flight medical faculties. I hope that in 2032, Estonia will have one Estonian university. If not, young Estonians will go off to study in Riga or Helsinki. A base for clinical medical studies has to be established in Tallinn as well.
Is there anything about our current way of life and society that will cost us a steep price in 2032?
Punab: People don’t understand that they themselves are responsible for their health and that doctors are only helpers. People should heal themselves. But a clear change can already now be seen in people’s health awareness. There’s been a sea change in the attitude of people aged 45 and younger.
Metspalu: We clearly see that new illnesses have become common due to the rapid changes in the environment, and these are manifested in the rise in average body weight, and an annual rise in the incidence of type 2 diabetes. People in the West are overfed and get too little exercise. This change has occurred in the last 100 years.
Genetic traits that once gave an evolutionary advantage and allowed energy to be stored as fat for leaner times are now proving our undoing. The next 18 years will be spent on turning the situation around dramatically. This can only happen in people’s minds and behaviours. Starting in early childhood, we have to identify who is most at risk and expend more resources on these individuals.
Lutsar: We can keep 100-year-old people alive using machines. The question is, if society is a place where old people live alone with their children and grandchildren scattered around the world, older people will have robots to assist them in place of family members. If Grandpa is replaced by Facebook and Grandma by Twitter, how can we convince these older folks that they still have some function in society? Extreme individualism in our current society will cost us dearly.
What’s currently in the pipeline in labs, what will family doctors have in their arsenal in 2032, what will people have on their nightstands?
Harro: People will have some kind of screen in their homes. It will be an improvement on our current computers, and will provide various kinds of feedback on their health that places their condition in the context of the rest of the world.
We will have diagnostic tools for psychological disorders, and they will be based on physics and chemistry. It could be a blood sample, functional brain scan or a functional test. Currently there’s no symptom of these disorders that isn’t self-reported by the patient. Diagnostics will thus be much more objective than they are now.
Lutsar: The emphasis will shift to diagnostics. People will be able to administer many tests at home and then go see a doctor once they have their results. Much can be modelled, we can already do computer modelling of the dosage of a medication for a 600-gram newborn. We won’t have to conduct long clinical trials with complicated protocols.
Will everyone in 2032 be carrying around their personal genetic code in their pocket, on some mobile device?
Metspalu: Absolutely certainly. It won’t just have the genome but the transcriptome as well. We’ll have more information by then on the direct influence of epigenetics. There will be ways of running labs quickly and inexpensively, and moreover, there will be so much information that can be interpreted right away. The metaphor here is that we currently know individual Chinese characters but in 2032, we’ll be able to translate an entire book.
Harro: Well, I won’t have it on my device. But that data will be quite uninformative by that time. I hope that by 2032 we’ll have more knowledge about the factors responsible for gene expression. For instance, how cells cooperate with each other. We will be capable of taking a relatively stable configuration of human health and assessing it dynamically.
Kõks: I think that genome sequencing will become even cheaper, and a more mass-market service. But should this information be on everyone’s phone? I don’t see the point why it should be needed on a smartphone? There certainly will be a database, and doctors will be able to access that information. A large percentage of the citizens of industrialized countries will possess their personal genome sequences.
How will this help medicine progress?
Metspalu: Let’s say a person smokes but knows that his uncle was a lifelong smoker who lived to be 95. He might claim that talk of hazards of smoking is hogwash. But maybe the uncle had a C nucleotide in a certain position and the nephew has an A. The nephew will die of cancer at 60 if he continues smoking. Seventy-five percent of people would want to change their behaviour upon learning something like that.
Harro: Such an individual nucleotide variation has less of an effect than was previously thought. And people won’t believe it, anyway. Most diseases are multifactorial, where the interactions between factors are what count, not the structural genome sequence. As to why one smoker develops a malignant tumour, this is due to many different pathways, which is why we can’t ever point at a single cause. We can bluff, assuming that the anti-smoking campaign is so noble a goal that we can integrate science and shamanism in its pursuit.
Punab: Evaluation of genetic risks could sow confusion that our medical discipline is not ready for. We have studied the personality traits of people who undergo prostate screening. There are more borderline neurotics among them. Alerting everyone to their genetic risks may lead to people with hypochondriac tendencies with even the most trivial concern queuing at clinics – at our current level of funding, we can’t serve every one of them.
Will insurance companies start asking to see genetic data before signing policies, with people with higher risk of illness simply denied coverage?
Harro: This is a serious risk and we will face it before we reap the real benefits of genetic knowledge. An insurer operates with the lives and health of thousands of people and has access to statistics. They may benefit from advances in science even before people do. They can use actuarial probabilities.
Metspalu: I wanted to take out a life insurance policy in Estonia back in 1999, and they asked for certificates from five physicians. If an insurance company turns someone down, I would set up a competing insurance company for those people denied coverage. Everyone has some problem. We’ve reviewed the records of 20,000 gene donors. If a person appears to be free of illness, then that just means there hasn’t been enough study.
How will Estonians’ health behaviour have changed by 2032?
Harro: People may become stratified. There are people with a very healthy lifestyle, and those who say they just don’t care.
Kõks: I hope people will be smart enough that they won’t believe in snake oil and diet fads. I hope their health behaviour will become more rational. They will have understood that an adequate holiday is important for the health, maybe they will realize that people don’t have to look like Barbies or movie stars, the main thing is that they are happy.
Will it be possible to print out livers and kidneys for transplants in 2032?
Lutsar: Work toward this is under way.
Metspalu: No, gene therapy has been around for 25 years, but this is still a field akin to repairing a jet plane in mid-air. We still know too little about stem cells.
Kõks: No, there won’t be organ printing yet, but there will be farms with hogs with modified genes, animals with human immune system genes – livers from such animals can be transplanted into humans.
The greatest medical breakthrough of the 20th century was the discovery of antibiotics. How about this century?
Harro: Direct brain stimulation and behaviour control. It may be possible even now to externally control mammalian behaviour. This is just as risky and beneficial an advance as nuclear energy. One can’t use magnetic fields to supply precise instructions to the brain, but direct implanted electrodes are a step ahead. An even bigger step is optogenetics – nerve cells have been made photosensitive and light stimulation can be used.
More complicated commands can be transmitted by connecting two brains. This is being done now with rats and primates, I don’t see any reason why it couldn’t be done with humans.
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