Can we look beyond the current COVID-19 pandemic?
“The UK has the potential to become world leading in wellness prevention…”
Professor John Deanfield
Professor of Cardiology, UCL
As a result of the current coronavirus pandemic, never before have health concerns been the number one issue for everyone. It has become clear that the outcome from COVID-19 infection is crucially dependent on background health rather than simply exposure to the virus. Furthermore, it is important to remember that after the coronavirus pandemic, the population’s health and life expectancy will remain largely determined by non-communicable diseases, such as diabetes, cancer, and cardiovascular disease. Treatment of these has improved dramatically but is expensive and threatens to become unaffordable in many countries. Globally, $47 trillion of cumulative economic output will be lost between 2012 and 2030 from chronic ill health. The present environment has exposed the need for individuals to take personal responsibility for their own health status without relying solely on the “disease care system” to keep them well. We are therefore at the beginning of a “revolution” in healthcare, with a much greater focus on wellness maintenance and prevention. Currently 70% of healthcare budget goes to disease management and 30% to prevention, whereas by 2040 it is anticipated that this allocation will be reversed.
Cardiovascular disease accounts for one third of all global deaths and drives health inequality. Two key observations have provided an opportunity to reduce “lifetime” cardiovascular risk. The first is that reducing exposure to well-known cardiovascular risk factors, such as smoking, cholesterol, and blood pressure, in a sustained manner from an early age produces leveraged gains in later clinical outcome. In UK Biobank (438,952 subjects), a lifetime, modest lowering of LDL-cholesterol and blood pressure (38.67-mg/dL and 10-mm Hg, respectively) as a result of a favourable gene profile was predicted to reduce future coronary events by 78%. The disease, which has ravaged the population in the twentieth and early twenty-first centuries, may thus be largely preventable with a change of approach. The second observation is that several important diseases of ageing share common biological pathways, involving inflammation and oxidative stress in response to cardiovascular risk factors, so that early reduction will benefit not just stroke or heart attacks but also diseases such as diabetes, cancer, and dementia.
A radical change in approach to “wellness” and “illness” is needed, with a new partnership between the healthcare system and the public. A top-class disease-care system can only be sustained if the public are empowered to take control of their health. The wellness agenda will need to include education, opportunity, and incentives.
In addition to these general population approaches, personalised medicine, involving genetic testing, imaging, and biomarkers, can identify individuals who have an accelerated trajectory to premature cardiovascular disease. “Real world” data acquired by digital technology, together with AI analysis, will enable prescription of existing and novel drugs to those who will benefit most. A new subcutaneous cholesterol lowering injection (Inclisiran) given twice yearly can lower cholesterol by approx. 60% and may transform future cardiovascular risk.
The UK, by virtue of its unified healthcare system, tradition of longitudinal data collection, investment in large-scale cohorts, and novel polygenic risk scoring, has the potential to become world leading in the new wellness prevention space.