The Nobel Prize in Medicine 2019 was awarded to three men for “their discoveries of how cells sense and adapt to oxygen availability”. The Nobel Prize in Medicine 2018 was given to two men “for their discovery of cancer therapy by inhibition of negative immune regulation”. The Nobel Prize in Chemistry 2017 went to a trio for developing “cool microscope technology” that “revolutionises biochemistry” by allowing researchers to study three-dimensional structures of biomolecules in their search for cure for the Zika and other viruses. One of the three chemistry winners of 2017, Joachim Frank of the US, said at the time that he “thought the chance of winning a Nobel Prize was minuscule because there are so many innovations and discoveries happening”.
Frank is still right about that. Technological leaps in medicine dubbed medtech are accelerating as researchers find better ways to treat more diseases, in more ways, for more people. Advances are occurring in biotechnology, immunotherapy, surgery, and foetal and neonatal care to name just some areas. Artificial-intelligence software trained on data from digitalised health records and devices can spot problems faster and more reliably than can humans. HCA Healthcare, the largest for-profit hospital operator in the US, for instance, now uses algorithms trained on 31 million cases to detect the sepsis infection that kills about 270,000 people a year in the US.
More medtech advances are certain. Money is pouring into research and development overseen by regulators and doctors to ensure benefits outweigh risks.
Common sights soon might be robot physicians, remote surgery and mini 3D-printed organs. Bacteria genetically reprogrammed to destroy tumours in mice could one day work on humans. Genome scans and gene therapies could become routine.
For all this promise, however, medtech comes with two certain and one likely drawback. The first definite disadvantage is that medtech is raising ethical issues that could stop the deployment of key advances. The two most sensitive are the gene-editing of foetuses (‘superbabies’) that could alter human experience and protecting the privacy of patient data, an issue highlighted in November when it emerged that US healthcare provider Ascension had secretly handed over the records of tens of millions of patients to data crunchers at Google. Medtech’s other certain shortcoming is the cost. Many advancements might never become mainstream because they could prove too expensive for governments burdened with budget deficits and heavy debt loads that are already facing rising healthcare costs as their populations age.
Medtech’s contentious disadvantage is doctors are finding that self-monitoring via devices, which often detects harmless abnormalities and fuels hypochondria, is leading to unwarranted anxiety, incorrect diagnoses and unneeded treatments. All up, medtech’s value to society will be tied to the extent to which these disadvantages limit the spread of its unquestionable benefits.
Many of medtech’s ethical issues could be resolved, to be sure, but that won’t be easy. Some medtech advancements, especially those based on AI, are economical. Medtech needs to be assessed with the perspective that there is much it is not solving. Medtech advances, for example, aren’t enough to avert the recent decline in life expectancy in western countries due to heart attacks tied to obesity. Medtech pharmaceutically does little for autoimmune diseases such as arthritis that afflict one in four US adults – though it is improving joint-replacement surgery. Researchers are yet to find a cure for infections made drug-resistant due to the overuse of antimicrobial drugs that the World Health Organisation says could kill 10 million people a year by 2050. Nothing medtech has come up with is usurping MRI scans and X-rays.
Be these as they may, medtech advancements are ushering in treatments that produce better outcomes for patients. Only time will tell how much ethical, economic and other possible drawbacks limit mainstream access to medtech’s benefits.
The biotech era
Eras become known for their medical advancements. From the 1920s to the 1950s, for example, the key medical leaps were vaccines and antibiotics. Later epochs might regard today’s advances to be centred on cell and gene therapy, robotic surgery and perhaps AI.
Hope for cures from gene therapy, an area of research that emerged from the late 1980s, accelerated in the early 2000s when the human genome was sequenced. And treatments are underway now and more are likely. Biopolymers (nucleic acid) are injected into cells to treat inherited eye diseases and immune deficiencies while researchers are studying how gene therapy could treat cancer, heart disease and diabetics. A stellar example of gene therapy improving lives is that a Novartis subsidiary has developed a one-time gene-based treatment (Zolgensma®) that is a curing treatment for children born with spinal muscular atrophy (who without this advance constantly need treatment over their short lives). The problem is one dose costs US$2.1 million.
Aside from the costs, gene therapy comes with other challenges too.
The finicky nature of genes has made progress slow. Other hindrances are rejection, side effects such as cancer, and the risk that other genes may be delivered to a cell. Some treatments are so risky authorities have halted them. Some ‘breakthroughs’ have proved false – a recent study debunks that a certain gene causes depression. That the ethical issues surrounding gene therapy are unresolved became an urgent issue in 2018 when two Chinese babies were born with modified genes.
Inventions to assist surgeons have proved faster to everyday use (and less problematic). Robots have aided orthopaedic surgeons since the mid-1980s and now help with general, transplant, urological and other procedures. One measure of their widespread use is that Intuitive, the US-based maker of the 1999-launched da Vinci® surgical system, counts that tens of thousands of surgeons have conducted more than six million procedures in at least 66 countries using its equipment. The benefits of robotic-assisted surgery are less invasive, more precise and safer procedures due to fewer and tinier incisions (microsurgery) and reduced human error.
While less-invasive surgery shortens hospital stays and robotic surgery’s lower margins of error reduce the need and costs of further treatment, robotic-assisted procedures are expensive. Assuming cost issues can be overcome, technology will expand its role in surgery and robots could use AI more extensively to help surgeons make more decisions.
AI’s use in healthcare goes well beyond surgery too. AI programs including chatboxes are diagnosing heart disease and cancer, identifying retinal damage, analysing suicide risk, streamlining drug-development processes, proposing remedies for multiple sclerosis, even helping the dumb speak. AI’ s promise is more timely, economical, convenient and streamlined treatments.
AI’s usual drawbacks apply, however. Personal data needs privacy protection, which can impede research. Data can be dodgy and data-training algorithms can be flawed and biased, which could lead to misdiagnosis. AI is vulnerable to hacking, whereby malicious tweaks lead to errors. AI’s deployment often runs ahead of peer review and ethical considerations.
A neurotic world?
One medtech achievement is to elevate the practitioner ‘Doctor Me’. The term (sometimes stated as Doctor You) is for when people use devices and self-testing to monitor their health or genetic risks.
Self-monitoring comes with many advantages. It can save lives. The unwell can gain comfort if their vital signs are normal. The data collected can help everyone’s health and allow people to find others with similar issues, which could provide clues for treatments and moral support.
The problem, however, is that Doctor Me has ushered in the ‘nocebo’ effect, essentially a form of hypochondria. The nocebo effect occurs when patients think they are experiencing a side effect to a greater degree than possible or when people fret they are suffering from an ailment that a test showed they are at risk of – say people self-tested as prone to Alzheimer’s imagine they have the affliction when they forget something.
A Stanford study of 2018 found the nocebo effect is ripe in self-testing genetics, a flagship area of medtech that is not foolproof. The expression could become ubiquitous soon because more people are testing their disposition to Alzheimer’s, cancer and obesity – by 2017, already one in 25 in the US knew their genetic data. If the nocebo effect becomes widespread, authorities may need to limit self-testing.
While future Nobel Prizes await those making medtech advances, perhaps others lie ahead for those who find ways to resolve medtech’s ethical, economic and hypochondriac challenges.
By Michael Collins, Investment Specialist
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not to mention the dramatic increase in the costs of delivering healthcare....