Emory University Signature Theme Deliverable
PREDICTIVE HEALTH AND SOCIETY
Kenneth Brigham, M.D. and Michelle Lampl, Ph.D., M.D.
Predictive Health and Society
I.
Statement of The Theme
“Predictive Health and Society” will bring together a universe of disciplines, technologies and
management skills to develop an integrated definition of health, the tools to measure it, new
interventions to maintain or restore health and an Emory model care system that is health focused,
science based and exportable to large populations. This theme will assimilate the University’s and the
Region’s unique resources, integrating research, education and health care into a dynamic program
that sustains continual discovery and translation of new knowledge into healthier individuals and a
healthier society in the US and globally.
Introduction
America's health care system is second only to Japan ... Canada,
Sweden, Great Britain ... well, all of Europe. But you can thank your
lucky stars we don't live in Paraguay! - Homer Simpson
America spends more on health than other countries, but the results are disappointing; we are
not healthier and we are not a model for other world societies. The US spends upwards of sixteen
percent of its gross domestic product on health; Japan spends about half that and health expenditures
in Switzerland, Germany, France, Canada, Sweden, Australia, Netherlands, Denmark, Italy and Great
Britain are all less than twelve percent of GDP. The rate at which health expenditures are increasing is
also greater in the US than elsewhere---2.7% between 1990-2002 versus, for example, 1.7% in Great
Britain and 0.3% in Denmark.
But, we are at serious risk of losing our health while paying dearly for it. If you are a woman
born in the United States you can expect to live about five years less that if you were born in Japan and
several years less than if you were born in France, Italy, Australia, Sweden, Germany or Great Britain;
men can expect about the same. At least by that important metric we are a less healthy people than
most of the developed world and we are falling further behind. Between 1960 and 2001 expected life
spans increased on average 9.2 years in those
other countries and only 7.2 years in the US. The
Figure 1: Interdependence of Individual and
realization is dawning on thoughtful leaders that
Group Health
the health care system in the US is not working,
not sustainable and nearing crisis.
Health matters because it is inextricable
from individual happiness, productivity and quality
of life, but also because human beings do not
Healthy
thrive in units of one---individual health and
Healthy
People
Societies
societal health depend on each other (figure 1).
Our health impacts our social equanimity, our
competitiveness and our influence for good
throughout the world. It is difficult to imagine an
area with a potential to impact the human
condition and civilization equal to that of
enhancing individual and societal health.
What are the possibilities?
For the most part, we have defined health passively (being healthy is not being sick) and we
have built a health care and biomedical research system that is focused on disease. That system
2
threatens to implode because remedial medicine costs too much, is too inefficient and often fails. The
focus on specific diseases may have been inescapable when medicine was largely empiric, the
scientific (and social) armamentarium was limited and expectations were low, but all that has changed.
Rapidly expanding knowledge is continually unearthing new evidence upon which to base health care.
Science, technology and sophisticated social inquiry promise opportunities for understanding ourselves
and our fellows with a completeness that we have yet to comprehend Emory University can lead
discovery and implementation of a new approach that will change concepts of health and health care--shift the paradigm---to the enormous benefit of people and credit to the university. We are uniquely
positioned with cross-disciplinary capabilities to address this issue. We can do well by doing good.
Proactive versus reactive
Figure 2 illustrates the current paradigm and how it can shift to advantage health.
Contemporary medicine is a disease care system, not a health care system. Applying resources to
defining health, developing tools to measure it
and interventions that, done early, maintain or
restore health, and developing a workable
implementation strategy, can produce an
Figure 2: The Health/Disease Continuum
efficient, cost effective, accessible system.
But, that is a big task, maybe an
unprecedented one. It must involve basic and
applied investigators from a broad range of
disciplines, from hard science to humanities,
including
not
only
geneticists,
D
H
nanotechnologists and the like, but also
I
E
S
economic
theorists,
business
experts,
A
E
L
epidemiologists,
chemists,
ethicists,
social
A
T
S
scientists,
health
behaviorists,
experts
in
law,
H
E
ethics, health policy, systems biologists, and
others.
And this array of experts must
function with a common focus and a
commitment to elaborate communication; research in each area must inform all others. The research
should be serious inquiry driven by the problem to be solved, sitting squarely in what Donald Stokes
called “Pasteur’s Quadrant,” pursuing understanding and use together.
A theory and how it could be explored is diagrammed in figure 3. There is accumulating
evidence that a limited number of generic processes are harbingers of many apparently different
pathologies of both soma and psyche. If those
Figure 3: Predictive Health and Society
processes could be easily accessed and
monitored, they would define health with new
depth and mark early deviations from health at
a time when interventions are more likely to
work.
The power of this concept is that
measuring generic biomarkers that predict a
host of diseases makes the task of developing
the analytic tools critical to predicting health
less daunting than the “one marker one
disease” concept.
Three examples. 1) A study conducted
in the Departments of Medicine and Psychiatry
at Emory, found that markers of oxidant stress
that can be measured in a blood sample
correlate with early markers of atherosclerosis
Normal
Low risk
Normal
High risk
Pre
disease
Early
disease
Late
disease
Predictive Health
Contemporary Medicine
Determinants of
Health
Environment
Genomics/
Metabolomics/
Proteomics
Genetics
Population
Biology
Behavior
Molecular Imaging
Systems Biology
Generic Pathways
Bioinformatics
Some
Enabling
Technologies
Nanomedicine
Quantitative
Medicine
Ethics
Immunology
and
Inflammation
Development
Oxidative
and
Stress
Senescence
Public Policy
Business, Finance
and Economics
Other Generic Regeneration
and Repair
Pathways
Novel
Therapeutics
Education
Specific Diseases
Cardiovascular
Diseases
Chronic Lung
Diseases
Cancer
Diabetes
Neurological
Diseases
3
Other Diseases
Some
Enabling
Disciplines
and kidney disease, but also with early signs of depression. 2) A recent study reported in the
Proceedings of the National Academy of Sciences found that the social stress of caring for a loved one
with a severe chronic disease caused molecular changes in blood cells that are associated with
senescence (decreased telomerase activity and telomere shortening). 3) Corey Keyes in the
Department of Sociology at Emory used a measure of mental health that included measures of
depression and of subjective well-being and found a clear relationship between this determination of
mental health as a “complete state” and cardiovascular disease. Understanding health and determining
how to keep it will require all kinds of expertise. The surface has been barely scratched.
Changing concepts of health and disease and of health care will both require and dictate
changes in how we educate health care professionals. This approach will also create entirely new
opportunities for education and research in the array of disciplines involved in the effort. The
integrated, “Pasteur’s Quadrant,” concept of research that is problem focused and inquiry driven will be
a fecund setting for innovations in learning and in enabling the process of discovery.
Definition of the topic
Predictive Health and Society should be broadly multidisciplinary, but problem focused. The
effort will include investigators and thinkers from the array of disciplines mentioned above, bonded
together by their conviction that individual and societal health presents great needs and challenges, but
even greater opportunity---maybe the greatest opportunity to have a positive impact on humanity that
will present itself to a community of scholars in our lifetime. These scholars will be committed to
interdisciplinarity to an uncommon degree. They will reach well beyond their specialty, learn the
multiple languages of other disciplines and commit to listening, learning and teaching as interactive
processes that inform the overall effort. Health as a theme can unify University Schools, Programs and
Departments, providing a major force for moving the University from a vertical model of parallel but
separate endeavors to a network of investigations with a focus that is a central social value with global
reach. As disparate societies become more interconnected, we share health concerns---modernization,
environmental changes, homogenization of lifestyles are not always healthier. Scientific innovations
from better drug development based on genetic knowledge of infectious organisms to targeted
intervention in individual lifetimes are imminent. A University-based endeavor brings the science of
health together with the ethics of well being and health decision-making and creates a forum for
exploring societal concerns. The universe of disciplines essential to addressing these common human
challenges exists only in Universities and Emory is especially well positioned.
Pre-emptive health care, vis-a-vis our present medical system, has profound economic
implications. For example, Figure 4 (see page 5) is a hypothetical comparison of how a disease based
system (contemporary medicine) and a health based system (the Emory model) might serve a person
born with a predisposition to develop coronary artery disease. Focusing on detailed health related
information and early intervention will decrease demand for expensive care of failing organs and
prolong high quality life. As technologies mature, the cost of obtaining, storing and interpreting health
relevant information will be such that this approach will be economically feasible. These challenges
demand the best minds of our Business School working in concert with other essential disciplines.
This theme can launch from a population-based initiative that will accumulate a database of
healthy people to be followed prospectively. This will not be a clinic for contemporary care, but rather a
test site for the new biomedicine. This population will be used to develop an integrated definition of
health and to determine how well candidate markers predict health, identify risk and detect
premorbidity. Strategies for effectively implementing predictive health care including economic models
will also be field tested in this population as will innovative interventions aimed at maintaining health,
minimizing risk and restoring health prior to overt disease. This component of the theme will be an
extraordinary opportunity to integrate clinical care with research and education in the many disciplines
that can influence both the process and the outcome.
4
0
10
20
30
2 5 y r , n a n o s c r e e n , e le v a t e d o x s t r e s s d e t e c t e d ,
r e v is e d d ie t , e x e r c is e a n d t h e r a p e u t ic
40
6 2 y r s , f a t a l M I w it h 5 d a y s
in I C U
5 3 y r s , f o llo w - u p P C T A
50
60
70
30
80
direct cost
indirect cost
$42,720
$37,920 (lost productivity)
direct cost
indirect cost
$15,000
$12,000 (lost productivity)
direct cost
indirect cost
$65,000
$500,000 (lost economic value x 20 yrs)
Total
$672,640
I n c r e a s e d lif e s p a n
N e o n a t a l g e n o m ic r is k a s s e s s m e n t
Emory model, risk evaluation
and early intervention
20
1 8 y r , m e t a b o lo m e s c r e e n c h a n g e ,
p r e s c r ib e d d ie t
10
B e g i n a n n u a l p h y s e x a m s w it h m e t a b o lo m e ,
p s y c h o - s o c ia l e v a lu a t io n , d e p r e s s io n s c o r e
a n d c o g n it iv e f u n c t io n
0
3 2 y r , c h a n g e in m e t a b o lo m e a n d n a n o s c r e e n ,
u p d a t e m e d ic a t io n s
Conventional medicine
4 7 y r , a c u te M I
2 2 y r , s ile n t a t h e r o g e n ic
changes
Figure 4: Hypothetical comparison of a disease focused health care model (Conventional medicine) with a health focused system (the Emory model)
for a person born with a predisposition to coronary artery disease
40
50
60
70
80
Neonatal risk assessment:
direct cost
indirect cost
Annual physical exam
direct cost
indirect cost
Nanoscreen added
direct cost
indirect cost
$9,300 ($150/yr x 62 yrs)
$0 (combined with annual physical
Add therapeutic
direct cost
indirect cost
$2,555 (7 yrs of drug at $1/day)
$0
Revise therapeutic
direct cost
indirect cost
$18,250 (50 yrs of drug at $1/day)
$0
Total
$45,605
5
$500
$0
$10,500 ($150/yr X 70 yrs)
$4,500 (time off work, .25 day/60yr)
II.
Differentiation and Transformation
What others are doing
A number of academic, private and industrial institutions have initiated programs that address
one or another part of the health care challenges and opportunities presented by developing science
and technology. However, these tend to be either focused exclusively on developing technology,
application of traditional preventive medicine programs or on commercial interests. Some examples of
programs being conducted in academic settings include the following:
Institute for Systems Biology This independent organization in Seattle, Washington, structured
as a not-for-profit, is fully engaged in systems biology research. Not affiliated with an academic
institution, but wearing some of the characteristics of academia, the institute is a purposely small,
focused, interdisciplinary group of scientists. Scientific areas of expertise include biology, physics,
chemistry, computing, mathematics, medicine, immunology, biochemistry and genetics, making this a
technologically broad interdisciplinary group. The work is narrowly focused on developing new
technologies in genomics and proteomics. The founder of this institute, Leroy Hood has written
extensively about what he calls prospective, predictive, personalized medicine. The concept is not
unlike what we propose, but the institute lacks both interest and expertise for translating the technology
to society.
Duke University The Duke healthcare model is heavily influenced by the Snyderman emphasis
on prospective health care. Duke is utilizing its employee population to build a prospective medicine
model utilizing personal health “coaches” to assist patients in successfully implementing their
personalized health plan. There is a formal collaboration between Duke University and the Center for
the Advancement of Genomics intended to create the first fully integrated practice of genomic medicine.
The Institute for Genome Sciences and Policy is the Duke response to the needs of genomic medicine,
and will play a key role in addressing the scientific and ethical issues surrounding this new practice of
medicine. This model is heavily weighted toward traditional preventive medicine at the clinical end and
genomics at the other.
Broad Institute Founded in 2003, this is a joint effort between MIT, Harvard University and the
Whitehead Institute. With origins in The Center for Genome Research, this center served as the
flagship of the Human Genome Project, the international effort to identify the blueprint for a human
being. Founded in 1990, the Center grew to become one of the largest genome centers in the world
and an international leader in the field of genomics, the study of all of the genes in an organism and
how they function together in health and disease. Today, the Center houses a broad range of thriving
research programs combining structural genomics, medical and population genetics, and clinical
medicine. The Center's annual budget is $80 million, and it employs 250 people, including scientists
and medical researchers from Whitehead, MIT, and Harvard. Like many of these programs, this effort
is heavily focused on genomics/genetics.
Washington University The BioMed 21 initiative, designed to reorganize and reorient the
biological sciences at Wash U., is intended to reshape University culture over the next 10 years. The
stated goal of the initiative is to rapidly convert the knowledge of the genetic blueprint of human beings
into effective, individualized treatments. This is a conventional initiative, taking place fully within the
academic and financial structure of the University. It occupies four physical locations: a reconstructed
area adjacent to the Genome Sequencing Center, a new 250,000 sq/ft building in the medical campus
for translational research, the Farrell Learning and Teaching Center, and a 40,000 sq/ft facility designed
to facilitate development of mouse models for human diseases. This is a program with the goal of
6
implementing genomics into clinical medicine with a focus on treatments aimed at established
diseases.
Johns Hopkins The McKusick-Nathans Institute of Genetic Medicine has as its mission to
further the understanding of human heredity and genetic medicine, and use that knowledge to treat and
prevent disease. To that end, the Institute is working to consolidate all relevant teaching, patient care
and research in human and medical genetics at Johns Hopkins and to provide national and
international leadership in genetic medicine. It serves as a focal point for interactions between diverse
investigators to promote the application of genetic discoveries to human disease and genetics
education to the public. It builds upon past strengths and further develops expertise in the areas of
genomics, developmental genetics, and complex disease genetics. In addition, it is hoped it will
catalyze the spread of human genetic perspectives to other related disciplines by collaboration with
other departments within Hopkins. This organization, located within Johns Hopkins, conducts basic
and translational genetic research. Their program emphasis does not extend to work beyond genetics,
and does not directly tie to other Johns Hopkins departments and centers. While collaboration with
other disciplines is a stated goal, it is not a hard-wired component of their structure. They have
launched a national “Johns Hopkins---Imagine” advertising campaign that appears to be based on the
concept of this institute.
What unique resources does Emory have and how can Emory lead?
Several concepts underlying a Predictive Health and Society theme at Emory differentiate this
effort from others. In addition, Emory and the Atlanta area have characteristics uniquely suited to
pursuing this theme. For example:
• A focus on health
We propose to focus this effort on health, not disease. That approach contrasts with many,
possibly all, of the efforts in this area at other institutions. Even predictive models are mostly
focused on identifying predictors of diseases rather than characterizing health. Emory has preeminent researchers who can re-conceptualize medicine as the definition and preservation of
health.
• Generic processes as definers of health
Other programs in predictive/prospective/personalized medicine are aimed at identifying
detectable markers of risk or pre-disease states that are specific for a given disease (e.g.
cancer, heart disease, diabetes). Our hypothesis is that there are generic processes that
characterize health, deviations from which indicate loss of health but are not disease specific.
The power of this concept is the implication that there are generic biomarkers that might predict
a host of diseases so that the task of developing the analytic tools critical to predicting health is
less daunting than the “one marker one disease” concept.
• A special environment
Emory University, The Woodruff Health Sciences Center, Georgia Tech, the CDC, the
Carter Center, the American Cancer Society and the population served by Emory HealthCare
together compose an environment rich in intellectual, scientific, technological and human
resources that is uniquely suited to developing and implementing a new approach to health care
that will illustrate the power of integrating diverse assets to focus on a critical social issue. The
“Emory Model” should become the benchmark for the new biomedicine.
• Unique combination of technologies
The technological expertise at Emory and Georgia Tech are cutting edge in several areas,
including nanobiology, imaging, genomics/metabolomics.
There already exist many
collaborative efforts in these areas that are both innovative and productive. The opportunity and
resources to bring these technologies together with a predictive health focus and integrated with
the broader scope of expertise that we propose is unique to this environment.
7
•
Integration of science, technology, ethics, humanities, law, business, health policy,
economics
Management challenges presented by this endeavor encompass fundamental leadership,
communication, motivational and collaborative processes; ethical, legal and political issues are
equally challenging. The focus not only brings science and technology together, but engages
the numerous other areas of expertise that will be essential to implementing a new approach to
health care and will make Emory one of a kind in the area and propel us to the forefront of
efforts to change the system. With the College, the School of Public Health, the Schools of Law
and Business and health systems programs at Georgia Tech, we have available a special
collection of relevant resources. The theme centers a major cultural value—health---at the
nexus of collaborative research among basic scientists, social scientists, and religious and legal
scholars.
• Systems science---cells to societies
The developing Systems Biology program at Georgia Tech brings a basic approach to
integrating biologic processes at a cellular level that will make major contributions to predictive
health. Designing social models that will function to implement a new health care system
involves a similar rigor in defining interacting networks and modeling responses to
perturbations. This theme could create new synergy by bringing together experts in both areas
with a common focus.
• Building bridges between population health and individual health
Traditionally, population based health initiatives and individual based approaches have been
separate activities. A predictive model of health care should impact both approaches and
development of the model should integrate information and issues across the spectrum from
individuals to populations. With the School of Public Health and the CDC we have extensive
involvement and expertise in population health and the opportunity to bring that perspective
together with the science, technology and individual focus is special.
Emory can move quickly to the vanguard of a new biomedicine by bringing together these
unique concepts and resources to focus on development and design of a workable system of care that
is aimed at defining and maintaining health. By integrating the range of disciplines essential to new
discoveries that span the spectrum from basic science through translational research to design and
proof of principle of a delivery system that is ethical, effective, economically viable and achievable in
this country and elsewhere, Emory can declare itself a destination university for health related matters.
What could it look like in ten years?
Emory can be a global center of societal health research, modeling the importance of integrating
bench innovations in technology into everyday health in a diversity of environments based on an
integrated approach that respects cultural diversity in beliefs, values and goals. Emory can be a
national example of the success of pre-emptive health care. Emory can become the University that
contributes to society at a time when the distance between achievements of the academy in general,
and science in particular, were distant from the general public. Emory can be the meeting place for
challenging discussions on the human condition.
A nidus of activity will exist around this theme involving international groups holding regular
symposia that are not unique to any discipline, because this will have become the standard for cutting
edge research. Programmatic research will include transdisciplinary seminars and regular publications
of scholarly treatises addressing different aspects of the challenge of health care. Formal activities
focused on predictive health and society will be central to the curriculum, involving faculty from Emory
college and professional schools, Georgia Tech, the CDC and other local institutions, identifying Emory
as a serious participant in design of the new biomedicine. These would be a draw for all of the Schools
and would provide a destination for international collaboration.
8
A substantial investment to create a new physical space would permit the academic home for
investigators from each of the key disciplines and provide resources for recruiting a few (5-10) faculty
who would complement current Emory and Georgia Tech faculty committed to this endeavor would
enable a quantum advance toward international preeminence in the area. Ten years hence, Emory
could be the leader in establishing a new biomedicine that would redefine biomedical research and
clinical care, invent new areas of scholarship by ignoring the boundaries of traditional disciplines,
provide an educational experience that prepares students to lead the next generation to further
advances in individual and societal health and favorably impact the productivity and well-being of the
broad community.
How can this theme transform Emory University?
Emory: A destination university internationally recognized as an inquiry-driven, ethically
engaged, and diverse community, whose members work collaboratively for positive
transformation in the world through courageous leadership in teaching, research,
scholarship, health care, and social action.
The Predictive Health and Society theme will relate to every component of Emory’s articulated
mission, contributing broadly to the transformation of the university envisioned in that statement:
•
•
•
•
•
•
•
•
A destination university---Emory can become a recognized destination for the new
biomedicine, a unique source of creative thought that integrates the several elements
essential to a new health system.
Internationally recognized---New knowledge and practical experience with health care
innovation will have global implications and will identify Emory as a world leader in this area.
Inquiry-driven---The entire effort will be driven by a passion for new knowledge and how it
can be used to impact individual and societal health.
Ethically engaged---Kathy Kinlaw says that “predictive health is fundamentally an ethical
concept”. Acquisition of new categories of information about people and how that
information is used, design of a delivery system that is fair and accessible, how societal
resources are allocated, etc., are ethical issues that must be addressed as an integral part
of the process of transforming health care.
A diverse community---Scholars involved in this effort will be drawn from across the
university and from other institutions in the area. The effort must address disparities in
health and research under this theme will result in definitions of health related diversity that
transcend traditionally defined ethnicities.
Working collaboratively---The nature of the theme dictates that a broad range of disciplines
must focus on the problem and dynamic interactions among a diverse group of scholars is
the core of this effort.
Positive transformation in the world---It is difficult to imagine an effort with as great a
potential to impact every aspect of society as the development of an efficient, equitable,
accessible, practicable, economically feasible system of care that preserves individual and
societal health.
Courageous leadership in teaching, research, scholarship, health care and social action--This is a bold theme with a grandly ambitious goal that integrates research, scholarship and
education in an innovative effort aimed directly at revolutionizing care of our citizens to
preserve and prolong the health of individuals and of society.
9
Realizing the potential of this theme will require both an institutional commitment and
enthusiastic participation of scholars from virtually every corner of the university. Creation of a physical
facility that enables multidisciplinary activities and resources for recruiting key faculty will be necessary
tangible commitments.
An ultimate measure of success of this effort would be an Emory model of health focused care
that is widely adopted as the benchmark of the new biomedicine. The model should be universally
accessible, affordable and produce healthier individuals and a healthier society. More immediate
measures of success include a university wide enthusiasm for and commitment to the theme,
successful attraction of dedicated resources from philanthropic sources, scholarly publications in the
many areas relevant to this effort, a change in focus of education of health professionals and students
in other areas to align educational experience with changing career expectations, a distinct Emory
influence on public policy related to health and extensive extramural support for the unique research
programs. The ability to attract high quality faculty and students into the program and to entrain them in
career paths in this area would be an important measure of educational success. An innovative
organizational structure that enables dynamic interactions among disparate disciplines that share focus
on a goal could be an academic model that would apply to interdisciplinary research and education in
general.
III.
Unanswered Questions
Several questions that can be anticipated are as yet unanswered and no doubt additional
questions will arise as the effort progresses. Some anticipated questions are:
• How will we overcome the inertia of an entrenched system with a long list of vested
interests?
• How can the effort be structured to realize the potential synergy of interacting
disciplines?
• How will the health care system in academic settings and elsewhere, be transitioned
from a disease focus to the Emory model while maintaining viability and continuing to
deliver the best available service?
• Will the change in health care occur by evolution or revolution (i.e. will the current
system implode, forcing dramatic change)?
• How will society in general respond to such a radical change?
• Is what we propose best communicated by the term “predictive health” or is there
something better?
• How can the concept be articulated in a way that captures the imagination of academics
and people in general?
• How much will it cost and how will it be financed?
IV.
Next Steps to Move Forward
Review of this theme as a candidate for a signature theme for Emory University will take place
soon and that decision will affect the appropriate next steps. In the meantime, we should
proceed with the planning activity already underway that is a collaborative effort of the Woodruff
Health Sciences Center and Georgia Tech. The university decision will affect the scope and
nature of the planning process as well as the people involved.
10
References
Epel,ES, Blackburn,EH, Lin,J, Dhabhar,FS, Adler,NE, Morrow,JD, Cawthon,RM. Accelerated
telomere shortening in response to life stress. Pro Natl Acad Sci USA 101:17312-17315, 2004.
Harrison, D, et al. The markers of oxidant stress (MOST) study. In process of publication
Keyes, CLM. The nexus of cardiovascular disease and depression revisited: the complete
mental health perspective and the moderating role of age and gender. Aging & Mental Health
8:266-274, 2004
Stokes, DE. Pasteur’s Quadrant: Basic Science and Technological Innovation. Brookings
Institution Press, Washington, DC, 1997.
The health of nations. The Economist July 17, 2004, pp 3-19.
11