TOWARDS THE 21st CENTURY:
MEDICINE IN TRANSITION
Sidney Goldstein, MD, FACC*
Henry Ford Hospital, Detroit Michigan, USA
The major challenge for the next century will be how nations are able to transfer advances in medical technology and therapy to their citizens. This is an issue that both the developed and the developing nations must face. The research productivity that has been so successful in the last half century will continue. The forces of technologic development that have been unleashed will be self-sustaining well into the 21st century. The investment from both the private and government sectors has developed a symbiosis that is self-propagating. Continuing support from both sectors will be required to maintain the momentum in medical research.
As the frontier of medicine moves forward, one discovery leads inevitably to another. The explosion of molecular biology has the potential to unlock the doors of disease states as well as the genetic propensity to develop diseases. Yet, these advances raise problems regardless of the state of the national economy. Can nations effectively finance the implementation of medical advances? Can they afford the progress made in treating and preventing disease?
The World Health Organization estimates the annual death worldwide to be 52 million. Eighty percent of these occur in the underdeveloped countries. Cardiovascular disease makes up 20% of the annual death, with almost 75% coming from the developed countries or those in transition. However, as economic development takes place throughout the world, the epidemiology of disease will also shift, with fewer patients dying of infectious disease. Individuals will live longer and consequently, the number of people facing disease in general and cardiovascular disease in particular, will also increase substantially.
As the economic revolution sweeps through the underdeveloped nations, demographic changes will have a major impact on the future expression of disease. This transition of national economies from rural and agricultural to urban and industrial has already taken place in North America and Europe. Many countries in Asia, and particularly Eastern Europe, are just beginning to face that economic transition. Economic prosperity has been associated with an increase in per capita income, which led to the investment in sanitary facilities and health care. Improvement in sanitation remarkably reduced the incidence of infectious diseases.
The resultant aging of the population will lead to major shifts in the demography of developing nations and those already in transition. Because of these economic and demographic changes occurring worldwide, we anticipate a major increase in cardiovascular disease. Therefore, as we prepare to move into the next century, it is imperative that we begin to minimize risk factors that have played an important role in the occurrence of cardiovascular disease in the developed world. Modification in diet and eradication of cigarette smoking, which already has a large presence in Asia, must be accomplished.
The advances in medicine that have occurred in the last fifty years have overshadowed the achievements of the early part of the last century. The first half of the century focused mainly on the description and classification of disease with archaic approach to treatment. Cardiovascular disease was mainly an expression of infection. In a large part of the underdeveloped world, infectious disease remains a significant cause of morbidity and mortality, even today. Coincident with the remarkable decrease in the incidence and mortality from infectious diseases, the incidence and mortality from degenerative cardiovascular disease increased substantially in the developed world.
Medical care of the aging, which is becoming an issue of great importance in the developed nations, is just beginning to emerge in the underdeveloped world. As we progress from one disease constellation to another, it is as though we are laying back one layer of disease only to uncover another. It is now clear that degenerative vascular disease _ the expression of aging _ will
*Division Head Emeritus, Division of Cardiovascular Medicine Henry Ford Hospital, Detroit, Michigan and Professor of Medicine Case-Western Reserve University, Cleveland, Ohio, USA
Address correspondence: Dr. Sidney Goldstein, Henry Ford Hospital, 2799 West Grand Blvd. Detroit, Michigan 48202, USA
be the next public health issue around the world. It has the potential to raise major issues in the assignment of national health care priorities. Within the determination of health priority lies the potential of setting one age group against another because the elderly place a heavy economic burden on the young. The aged will become increasingly dependent on the work and resources of the young.
Although the integration of new therapy into society is an important goal, the optimization of preventive care has the potential to have an even greater impact on health. A large part of the world still faces the problems of infectious disease and rheumatic fever prevention. Even when antibiotics are available, their distribution to populations remote from health care facilities poses major problems. The lack of health care workers and physicians in remote areas of the world continues to pose major obstacles to the provision of adequate medical care. In the developed world, the establishment of medical facilities attracts young physicians. But funds to accomplish this in the underdeveloped world are not readily available. The inequitable distribution of medical facilities and physicians is apparent in rural areas of many developed nations, but the disparity is more striking in underdeveloped nations. Nations must resolve the unequal distribution of health care workers and establish easy access to health care facilities. These are important goals for all nations.
In many countries, regardless of their state of development, major economic barriers to health care do exist. Economic barriers touch on rich and poor countries alike. The cost of health care challenges the national budgets of countries worldwide. However, the magnitude of those challenges differs widely among nations. In the developed and transition countries, the application
of new technology and costly therapy has taken the provision of modern health care out of the hands of the individual and placed it on the shoulders of national and social services' budgets. As health care fund occupies a larger and larger portion of national budgets, nations must make the decision as to where taxes and social welfare budgets are positioned. Whether nations can provide heart and kidney transplants rather than maternal and childcare are recurrent issues in the developed world. New and expensive therapies such as antibiotics for resistant infections or cholesterol-lowering drugs have become widely available and desirable to large parts of the population. However, these new advances place huge burdens on health care budgets. When individuals in developed countries are denied new therapy, they feel as deprived as the family in remote areas of the underdeveloped world who have no medical clinic or physician in their village. In the underdeveloped world, provisions of the most rudimentary necessities of medical care are beyond their economic capability.
The next century will be faced with wonderful opportunities for treatment, but major challenges of how to obtain them. The advances of medical research have opened the door to therapeutic options that have never been imagined in the past. Yet, the application of these new treatment modalities will be faced with significant geographic and financial barriers. Nations will be required to make difficult decisions in regard to the prioritization of their resources. Degenerative disease, especially atherosclerosis, will become a major health problem as the population throughout the world becomes older. How nations, both rich and poor, apply new medical therapy and technology will be the challenge of the next century and beyond. © 1999 Hamad Medical Corporation.