Prospective Health Care: The Next Health Care Transformation?

Overview

Given that there are about 47 million uninsured people in the U.S., ensuring universal health coverage has understandably become the key health care issue of this year’s presidential race.  However, there is another health care issue which deserves equal attention: our approach to health care.  The U.S. spends far more than any other nation annually on health care, yet does poorly in terms of health outcomes.  One report found that the U.S. health care system ranked last compared to Australia, Canada, Germany, New Zealand and the U.K. in terms of quality, access and efficiency despite spending twice as much per capita on health care.  Other studies showed that the U.S. rated 27th in both life expectancy and infant mortality.

Of the many factors contributing to this sub-optimal status, perhaps the most fundamental one is the ineffective prevention or coherent management of chronic diseases.   Consequently, chronic conditions, many of which are preventable, account for the majority of morbidity, mortality and costs each year in the U.S.  A more rational approach should emphasize health promotion and disease prevention or minimization through strategic health planning.  This personalized, predictive, preventive and participatory approach (4P medicine) is also known as “prospective health care.”

Through your core courses you will learn about, discuss, analyze and challenge the current health care situation and prospective health care as well as other issues from unexpected, yet relevant perspectives: religious, historical and immunological.  These will be complemented by clinical, research, business and policy viewpoints through the cluster’s Interdisciplinary Discussion Course.

During our inaugural year we traveled to Washington D.C. to meet top health care officials at world-famous institutions such as the NIH and Brookings; we heard from, questioned and interacted with guest speakers such as the Chancellor Emeritus of Duke University and the CEO of a California-based life sciences merchant bank; and through our cluster some students taught health care at a middle school to 7th and 8th grade boys on a weekly basis for one semester.  Even though our Focus cluster officially ended in December, involvement for many students did not. Some ended up doing research in the lab of one of our Focus professors while others joined the undergraduate Duke Prospective Health Care Club.  As one can see, this Focus cluster is for the student who not only wants to experience education beyond the classroom, but who also wants to play an active role in shaping health care.

Courses

Seminar: Religion 89FCS Religion & Health: Practices, Priorities & Possibilities

Keith G. Meador, Professor, Psychiatry & Behavioral Sciences; Co–Director, Center for Spirituality, Theology & Health

The relationship between religion and health is an old one, but research and renewed interests of the last couple of decades have enlivened the conversation and exchange at their intersection.  What might have seemed to be an engagement of lost relevance—with contemporary practices of medicine having become more refined and grounded in substantive advances in science—has instead gained increased significance as we come to understand better that optimal utilization of the advances we are making in medicine requires a more comprehensive grasp of the contributors to human motivation, self–understanding, and formation in personal and communal practices that affect health and health care.  Prospective health care engages all of these dimensions of health and offers an innovation in health care within which to examine religion and health as part of an increasingly urgent cultural conversation.

This course will include a review of the social and historical context within which the relationship between religion and health has evolved, and will examine the scientific and medical literature with regard to relevant associations and implications for health and health care.  With in that context we will consider the significance of diverse religious traditions as contributors to the current understandings reflected in this literature and how they inform the ongoing conversation.  The significance of religious traditions and communities in the formation of cultural understandings of health and illness—as well as in the formation of personal identities and narratives—and their relevance to health and health care practices will be considered.  Along with ethical issues such as resource allocation and possibilities for preventive health care, we will examine the dynamic relationship of health care providers and patients within the intersections of religion and health.
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Seminar: History 89FCS Revolutions in Medicine: Prospective Health Care & the History of Medical Technology

Jeffrey P. Baker, Associate Professor, Department of Pediatrics, School of Medicine; Assistant Professor, Department of History; Director, History of Medicine Program, Trent Center for Bioethics, Humanities & the History of Medicine

Medicine before the 20th century resembled a craft more than a science.  Patients and practitioners valued the arts of listening and observing, tailoring therapy to the unique constitutions of the individual patients. Over the course of the 20th century, the center of gravity of the clinical encounter shifted profoundly. Physicians today conceive of their work much more along the lines of an applied science, with laboratory studies, technology, and protocols increasingly taking precedence over the patient’s narrative and doctor’s clinical judgment.  The legacies of this transformation are complex: medicine has become more effective and curative, yet also more impersonal, standardized and expensive.

This class will consider prospective health care as a paradigm that, while based on science, promise to restore priority to the individuality of the patient.  We will examine it against context of the major innovations of the past two centuries that have promised to revolutionize patient care — some successful (bacteriology), some that repeatedly fell short of ambitious goals (the war on cancer).  Our goal will be to explore the ways in which earlier technologies transformed medical care in ways both expected and unintended, as well as how they reflected and even reinforced prevalent cultural values.  The final part of the class will focus more specifically on genomics and predictive medicine since the 1960s, analyzing current questions in the context of the history of medical technology.

Readings will primarily involve scholarly articles and primary sources. In addition, students should purchase the following: Doctors: The Biography of Medicine by Sherwin Nuland, The Breast Cancer Wars by Barron Lerner, The Troubled Dream of Genetic Medicine: Ethnicity and Innovation in Tay-Sachs, Cystic Fibrosis, and Sickle Cell by Keith Wailoo and Stephen Pemberton, and Better than Well: American Medicine Meets the American Dream by Carl Elliott.
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Seminar: Immunology 84FCS Evolution & Disease: Immunity, Microbes & Medicine

Thomas Kepler, Professor of Biostatistics & Bioinformatics, Department of Immunology, School of Medicine; Director, Laboratory of Computational Immunology

Cliburn Chann, Assistant Research Professor, Department of Biostatistics and Bioinformatics

Humans live in intimate association with hundreds of species of microorganisms and come into fleeting contact with thousands more.  The coevolution of humans and their symbiotic microbes has had a profound impact on human biology and consequently on human susceptibility to disease.  As culture and technology bring changes to human ecology, the human internal ecology — the balance between infection and immunity — changes in response, with striking impact on human health.

Antibiotic drugs once gave us reason to hope that the world might eventually be rid of its plagues, but we have come to realize that resistance to these compounds inevitably arises and spreads rapidly among microorganisms, limiting their effectiveness and use.  Furthermore, it appears that greater levels of sanitation found in the developed world is at least partially responsible for the increased incidence of allergy and asthma observed there. And while some diseases are confined to the developing world, HIV/AIDS serves as a potent reminder that human ecology transcends cultures and continents.

In addition to the many infectious diseases that are familiarly ascribed to microbes, several other diseases not traditionally regarded as infectious are now known to be caused by microorganisms (e.g., gastric ulcers and cervical cancer).  The immune system is responsible for many autoimmune diseases and plays a major role in cardiovascular and neurodegenerative diseases.  As one important component of prospective medicine focus on the clues found in individual genomes, we call attention to the medical relevance of the inter–individual and the inter–species interactions that shaped these genomes and continue to exert enormous influence on the health of the people who carry them.

In this class, we will study the role of the immune system and human microbial symbionts in human disease from an evolutionary and ecological perspective.  We will begin with introductions to molecular biology, evolution, microbiology and immunology.  We will then study specific diseases and processes, which may include: malaria, sickle–cell trait, cholera, gastric ulcers, tuberculosis and drug resistance, retroviruses, allergies and asthma, diabetes and Crohn's Disease, cancer, cardiovascular disease, Alzheimer’s Disease and schizophrenia.
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Focus 99 Special Topics in Focus: Prospective Health Care

Ziggy Yoediono, Senior Research Fellow, Center for Research on Prospective Health Care

This course — also known as the Interdisciplinary Discussion Course (“IDC” for short) — provides a unique opportunity for all the students and faculty within this cluster to meet weekly over dinner and engage in discussions with one another as well as to learn about and from each another.  In 2007 we debated issues such as “what do you think about the evolving field of genomics and its relevance to health care,” “would you want to know if you were at risk for diseases,” “what have been your experiences with the health care system,” and “do you think prospective health care can be realistically practiced.”

In addition to such discussions, we also invited guest speakers such as the former Chancellor of Health Affairs/CEO and President of the Duke University Health System; the Founder and CEO of a San Francisco-based life sciences merchant bank; and a business school student from China who spoke movingly about her experiences with the Chinese health care system.  We also hosted a career session for this Focus cluster where students got one-on-one time with a health care marketing professor from the Fuqua School of Business; the director of the Duke Clinical Research Institute; and the co-director of Duke undergraduate studies/professor of the practice of computer science.  We integrated an overnight trip to Washington D.C., where we received a personalized tour of the endocrinology unit at the National Institutes of Health (NIH), had a one-to-one meeting with Barack Obama’s health policy advisor and met with a nationally recognized health care economics expert at the Brookings Institute.  And finally, about one-third of the students joined a voluntary initiative developed just for this cluster where they taught health care to middle school boys at the Durham Nativity School on a weekly basis.

The best part is that such initial excitement has translated into sustained interest even though the semester ended.  Some students joined the undergraduate Duke Prospective Health Care Club while others are doing research in one of our professor’s labs.  Fall 2008 should be no different in terms of the exceptional experiences, people and perspectives to which you will be immersed.  We provide the basic tools for you to begin creating a phenomenal library of knowledge and, more importantly, application of knowledge.  The rest is up to you.
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