Francesca Tomasi received her B.A. from the University of Chicago and currently researches tuberculosis drug targets in search for novel antibiotics.
The seventeenth century brought with it major scientific breakthroughs, from Galileo’s telescope in 1609, to Antony Leeuwenhoek’s microscope and visualization of bacteria in the 1670s, to Isaac Newton’s laws of motion in 1687. In the eighteenth century, we met the steam engine and the world’s first battery, which led us in the nineteenth century to build electric motors, take photographs of nearly everything, click away on typewriters, and make light bulbs for the very first time. In the 1900s, innovation and discovery accelerated with airplanes, cars, rechargeable batteries, satellites, cellphones, and computers. At the same time, advanced technology and biomedicine were espoused to usher us into the era of modern medicine with antibiotics, transplants, and sophisticated full-body imaging techniques. Today, in the twenty-first century, we take things like the Internet, global communication, smart phones, DNA sequencing machines, supercomputers, and antibiotics for granted. More people in the world right now have access to a cell phone than to a toilet. Technology exploded into our world today and continues to grow in every sliver of society.
This technological explosion comes from Moore’s Law: literally speaking, the number of transistors per square inch on integrated circuits (the building blocks of computers) has doubled every year since their invention, suggesting exponential growth. An
The age of exponentially-growing technology and its seemingly infinite new directions comes with the caveat that society does not behave the way its inventions do. Yes, it seems to in some parts of the world: look at major cities like Tokyo, Boston, Abu Dhabi, San Francisco, Seoul, and Shanghai, with their futuristic architecture, proficient transportation services, and impressive hospitals. Millions of people keep up with technology and reap its many benefits. They get smartphones and barely miss a single beat whenever something new happens or is discovered. They get their genomes sequenced in search for any hidden hereditary diseases. They get CT scans, MRIs, and x-rays when there is (and when there isn’t) something wrong. They undergo the most cutting-edge treatments when they get sick. They live healthier and longer, technology becoming essential parts of their lifestyle.
The problem is that Earth’s population is in the billions, not the millions, and this leads to something called a law of negative returns: the more you add to something, the more it will decrease growth and production. In our case this means that, in some instances, the more cutting-edge technology you apply to fix one problem, the more it marginalizes those who cannot afford to fix that problem using that kind of technology, and the more problems it creates. One population suddenly has fixed their problem, while another not only is unable to, but is also left behind because the mere existence of a solution leads to the conclusion that the problem itself has been fully resolved. No one really tries to (or feels the need to) come up with a better solution for that other population.
While I was writing this article, a notification appeared on my phone from CNN: “How rich do you have to be to breathe clean air?” The question seemed fitting for the purposes of my article, so I swiped right to read it. It was a piece about Beijing’s smog. The story opens with an anecdote of a woman who wakes up every morning and the first thing she does is check to make sure her daughter is breathing clean air. She then proceeds to make breakfast – with organic foods that she washes with specially-filtered tap water. Then she drinks specially imported bottled water. All in the name of minimizing the toxic effects of living in one of Earth’s most polluted cities. The anecdote wraps up with “[b]ut for Beijing's rising middle class and poorer residents, this high-end home equipment is financially out of reach.”
It’s great that there are resources to pollution-proof a poisonous environment. Technology has allowed us to purify contaminated food and water, and to protect ourselves from the potentially harmful microbes or chemicals that might otherwise taint our sustenance. Technology has allowed us to treat countless diseases that would otherwise kill millions every year, and to produce more food for people who would otherwise go hungry. Technology has allowed us to communicate, to teach, to push the boundaries of science, to take us closer to understanding the universe.
But sometimes we get ahead of ourselves with technology. We can “pollution-proof” Beijing with some great technology, but only if we buy a multi-million-dollar home and install several extra thousands of dollars’ worth of filtration systems and air purifiers. As the CNN article points out, China’s pollution problems come from a massive economic boom that skyrocketed the nation’s material wealth, and made several thousand people rich beyond their dreams, making it okay to continue producing a massive amount of pollution. The mass implementation of technologies to produce things at unprecedented rates allowed China to emerge as an economic sensation, exponentially elevating the country’s economy. The wealth that poured over the people at the head of these efforts enabled them to develop technology that in turn keeps them safe from the harsh environmental consequences of their innovation. Thus the rich got richer and stayed healthy, while the poor got poorer and sicker.
Today, nearly one third of deaths in Chinese cities are attributed to pollution. This presents a law of negative returns: the more you add to fix one problem, the more it marginalizes those who cannot afford to fix that problem, and the more problems it creates, because the problem has not been fixed for everybody affected. Instead of undergoing a major public effort to reduce smog in urban China to acceptable levels (a public health solution to a problem whose source we fully understand), individualized, elite pods of healthy escapes – purified apartments, bottled air imported from the UK, vacation homes in the countryside, private doctors – allow the bigger issue to propagate. A law of growing returns (China’s economy) is on a see-saw with a law of negative returns (the polarizing pollution problem).
The same is true in medicine. There are some incredible advances in research that have opened the doors to so-called personalized medicine. We have identified specific genes, environmental and behavioral risk factors, and pathogens that are responsible for many acute and chronic conditions. We have ways to directly visualize bacterial infections raging their way through somebody’s body, and are working on ways literally to steer the right antibiotics to vulnerable sites. We have discovered ways to (eventually) implement gene editing to mitigate people’s risk of getting certain types of cancer, autoimmune disorders, or infectious diseases. We can grow organs and perform rejection-free transplants. We have at-home sensors and personal health-monitoring devices that sync with our smartphones and our doctors’ computers. Robotic surgeons help minimize risks inherent to human nature and boost survival rates for complicated procedures. Nanotechnology lets us deliver drugs or sensors throughout the body for therapeutic purposes. It’s amazing.
In our journey to push the boundaries of science and medicine, however, we seem to have cast aside – perhaps temporarily – the idea of access. Everybody in the world would benefit from the medical tools named above. But what percent of the world will realistically get the opportunity? Consider tuberculosis. According to the WHO, it is one of the top ten causes of death worldwide, but over 95% of TB deaths today occur in low- and middle-income countries. With the advent of antibiotics to treat TB, nearly 50 million lives have been saved since the year 2000, yet 1.8 million people still died of TB in 2015 and another 10.4 million people fell ill with it. Now, drug resistant tuberculosis is on the rise, with nearly half a million new cases in 2015 bearing this label. This means that current antibiotics are not sufficient, and stronger diagnostics are essential to identify drug resistant cases as early as possible to prevent further spread.
In 2010, the WHO endorsed a cartridge-based nucleic amplification test called GeneXpert to rapidly diagnose cases of drug resistant tuberculosis. The test works by using PCR (polymerase chain reaction), a technique that amplifies specific DNA sequences to detectable levels. The Xpert MTB system purifies and concentrates M. tuberculosis from patient sputum samples, isolates the bacterial genomes, and uses PCR to amplify any known genes associated with certain types of drug resistance. While a drug-susceptible sample of TB will not have these gene sequences and will therefore not yield any detectable amplification, a strain that is resistant to rifampicin, for instance, will carry a certain sequence in one or more genes that the Xpert will detect and amplify. The test spits out results in 90 minutes, a major contrast from the usual 4-6 plus weeks it takes to diagnose TB infections. Xpert is listed as easy to use, and apparently requires little technical training to operate. In 2013, UNITAID invested $25.9 million to purchase over 220 Xpert machines and 1.4 million test cartridges for 21 nations across Africa, Eastern Europe and Asia.
Xpert TB has done well in many countries. The WHO has even published an interactive map indicating what nations have procured new TB diagnostics, which include regions with some of the highest rates of TB infection in the world. According to a review of the Xpert rollout, since 2011 over 16 million tests have been performed in 122 countries. The detection of MDR TB has furthermore increased at least 3-fold compared to conventional methods. However, the review also points to several significant gaps. The authors state that the rollout “has been hampered by high costs for under-funded programs, unavailability of a complete solution package…and lack of impact assessment.” Simply put, comprehensive training, quality assurance, implementation, maintenance, and an actual connection from diagnosis to treatment require more attention. Significantly improving diagnosis can help reform behavioral practices to limit the spread of disease, but without structured treatment implementation to follow diagnosis, cure rates will not increase on their own.
In some areas of high-burden tuberculosis where Xpert technology would help dramatically, boxes of Xpert remain untouched, accumulating dust. There are many reasons for this besides the logistical ones mentioned above: different cultures might subscribe to different theories of disease. They may have their own health practices that seem to work just fine in a crippled healthcare infrastructure that under-reports cases. They may not have reliable power sources in their clinics to keep the machine going consistently. Any glitch along the process will sacrifice the quality of diagnosis and possibly promote distrust or obliviousness to inaccurate results. This, in turn, fuels an epidemic rather than quenching it. We think we solved the problem of diagnosing drug resistant TB with sophisticated tools like the Xpert, but we really might have further marginalized some populations that would greatly benefit from a quick and dirty (I say that figuratively, of course) way to diagnose TB infections. In these populations, drug resistant TB continues to spread mostly unchecked.
These stories do not have to have sad endings. CNN’s article about China point to the Kuznets curve, a hypothetical “inverted U” relationship between environmental quality and economic development: once average per capita income reaches a threshold, the environment starts to improve. Right now, we are at a point in which per capita income is on the rise in China, as is environmental degradation. The upper class has reached a level of discretionary income that allows them to afford anti-pollution efforts. If or when the middle and lower classes reach the same point, the Kuznets curve threshold will be reached and everybody will be able to afford to do something about pollution: hit the problem at its source, and hold public leaders accountable for progress.
A Kuznets curve for medicine may also stand a chance. In wealthy parts of the world, privatized hospitals and pharmaceutical companies become richer with medical innovation. When they want to pour resources into preventives, diagnostics, and treatments, they can. The world is full of benefactors, charity organizations, and cooperative governments that genuinely care about global health and do their best to pour resources in areas of desperate need. Many individuals and companies around the globe have come up with brilliant ways to reduce healthcare costs and increase access to treatment for countless illnesses. The global burden of these diseases have been mitigated – and in some cases, completely eradicated. The problem is not a lack of desire to help, or a lack of resources to do so. The problem instead lies in the type of help. Sending hundreds of robotic diagnostics to rural Africa or India will be met with just as much skepticism as an American doctor at a research hospital being told to diagnose drug susceptibility in a TB patient by cycling through antibiotics until something works. Medical technology is amazing, and it saves hundreds of millions of lives every year. But an exponential growth in the power of medical technology cannot realize its full potential if its side effect is increased marginalization, or negative returns on the world’s overall health.