Chapter Fourteen: Flattening The Earth

Tom Oates (@toates_19) is a nephrologist in London, UK. He was previously a Chain-Florey Fellow at the MRC Clinical Sciences Centre, and was awarded a PhD for work examining the role of DNA methylation in crescentic glomerulonephritis during this time. His clinical interests are in glomerulonephritis and transplantation but he practises in all areas of nephrology.

In chapter 14 of The Patient Will See You Now, Topol introduces the idea that globalisation has, over the past 20 years, seen an upswell of traditional developed world diseases such as diabetes, cancer and heart disease in the developing world. But, Topol says, “although that might mean new health risks, it also means new health opportunities.”

Topol, however, is not so foolish as to dismiss the traditional developing world communicable diseases of diarrhoea, TB and HIV. This is wise as it allows him to list a collection of ‘wow factor’ inventions that use smartphones, inexpensive add-ons to smartphones and mobile Internet connection to tackle these diseases.

Some of these are great, it would take a heart of stone not to be gladdened by the idea of taking ten minutes to assemble an origami microscope, attaching it to your iphone, and then using it to visualise a trypanosome. Or how about deploying a “rugged...microlaser” to transdermally detect haemozin-generated vapour nanobubbles which emit a “Hunt For Red October” style sonic hum when they contact malaria parasites. But innovation is not necessarily followed by benefit, and the references Topol cites for these new ideas are largely descriptive or promotional, not evidential.

He moves on to provide a similar look at tools for the developing world in non-communicable diseases - urine nanoparticles for tumour detection, sunlight driven polymerase chain reactions - and again, the accompanying references are technology descriptions and press releases as opposed to peer reviewed presentations of evidence.

Every so often evidence breaks through. When it does, it is from a level removed from the bleeding edge of nanoparticles and microfluidics: text message birth registration allowing vaccination planning, antibiotics for malnutrition, training nurses to perform caesarean sections. I am neither dismissing Topol’s world of innovation nor the incredible achievements of the inventors he lists. After all, the point of his book is to consider how the future path of medicine will venture deeply into the digital space, and how this space will make medicine a participatory experience for patients. It cannot be denied that the explosion of mobile technology will bring benefit to resource starved communities. But, for me, if you choose to write about medicine in the developing world, you should at least acknowledge the herd of elephant in the room.

The priority for flattening the health care earth is not currently in innovatory diagnostics, it is to broaden access to testing, treatment and prevention of HIV, malaria, TB, diarrhoeal illnesses and protein-energy malnutrition. Point of care testing for HIV is now commonplace, and the landmark AQUAMAT trial, which showed the benefit of treating African children with severe malaria with artesunate, used inexpensive point of care tests that have been around for many years.

I hope the dream of Chinese, European or North American physicians providing telemedical consultations to developing world patients bearing results of tests provided by innovatory diagnostic inventions comes off. But, quite frankly, not before all those who need HIV drugs and mosquito nets have access to them.