Wednesday, March 12, 2008

Thinking Outside the Box

We face numerous challenges as we aspire to promote our health prospects. Humans are intrinsically vulnerable to disease. In some cases we do not (at least yet) know how to effectively treat or cure certain diseases. There is currently no cure for cancer, or Huntington’s disease, Parkinson’s, etc. But we soldier on, searching for new ways to mitigate the often tragic consequences of our biological vulnerabilities.

And yet in other cases we already know that there are certain preventative measures people could pursue that would reduce disease and extend the number of healthy years they enjoy. For example, limiting the consumption of alcohol, quitting smoking, consuming a healthy diet, exercise, etc. All these things would reduce the risk of disease, and if everyone did them the benefits (to our health and economy) would be enormous. And yet people don’t do this. Despite knowing the things we know, smoking still kills millions every year, and obesity is a global epidemic.

So getting people to actually pursue the course of actions that could extend their health prospects can be tricky. The real value of particular interventions largely depends on the *likelihood* that they will have the desired benefit. And so knowing that intervention X can promote our health is only part of the battle. Getting people to utilize X can also be a challenge. And as this recent NICE report illustrates, these challenges can be very formidable.

What got me thinking about these issues? The latest issue of The Lancet has an interesting study (of a phase 2 clinical trial) on a new vaccination for hypertension. You can listen to the podcast here.

According to this report from the World Health Organization, hypertension is estimated to cause 4.5% of the current world disease burden and is almost equally prevalent in both developed and developing countries. And in the summary of this WHO report it is noted that: “Whereas the treatment of hypertension has been shown to prevent cardiovascular diseases and to extend and enhance life, hypertension remains inadequately managed everywhere”.

So even though we know that changes in lifestyle (e.g. diet and exercise) can help reduce the risk of hypertension, this environmental intervention is only effective if people actually comply with these guidelines. And many of us do not. Should we try harder? “Yes!” But at the same time, we need to entertain the prospect that other, less burdensome, interventions might also be available. And if they increase the likelihood of the benefit in question (i.e. reducing risk of disease) being realized then we should pursue them.

I was really struck by the fact mentioned in The Lancet Podcast, that when it comes to just taking drugs to treat hypertension, 50-80% of patients fail to take their recommended prescriptions. So even something as basic and simple as taking a pill can prove to be a formidable obstacle (forget about getting people to exercise and watch what they eat!).

And these kinds of considerations are a large part of the reason why I think we really need to take seriously the prospect that the biological manipulation of humans may prove to be a very effective way of expanding our health prospects. The less burdensome the measure, the more likely it is that the expected benefits would be realized. Though of course we have a very long way to go in terms of the safety and efficacy of new interventions like genetic manipulation. But the burdensomeness of an intervention is extremely important. And those who eschew new biotechnologies by saying “People just need to eat better and exercise!” are, in my opinion, not giving these complex issues due consideration. Redesigning our cities, to make them more conducive to human health, could prove to be an even bigger challenge than modifying our biology!

So, this all ties in with The Lancet article as researchers are exploring the prospects of a vaccine for hypertension. And this is somewhat similar to the imaginative strategies being pursued with resvertraol and the treatment of diabetes. The moral of the story: “we shouldn’t limit ourselves in terms of the strategies we consider for promoting human health!”. Few recognized the magnitude of the health benefits of the sanitation revolution when it was occurring in the 19th century. And I suspect the same might be true of the genetic revolution in this century.