High-Tech and Low Economic Status

With hopes to wow and inspire, Jay Walker gave an animated speech on the future of technological innovation and its implications for public health to kick-off Mailman Grand Rounds back in September. Rather than enthusiasm for Walker's envisioned future, however, those who commented voiced a number of ethical concerns. Some felt confident these advances would only exacerbate existing racial, ethic, socioeconomic, and regional health disparities. Some, like me, shifted in their seats at the thought of this technology transporting us into new and unfamiliar territory. Would these new advances actually improve health? Would the values we hold today survive the journey?

The audience’s focus on equity made me think: what about the technology we accept today? Does our current technology help to reduce health disparities, or does it only better the lives of a select few?

Despite the audience's concerns, Jay Walker warned that there isn’t much we can do but embrace what he calls the 10 "Super Forces" (bio sensors, nanotechnology, and robotics, to name a few).

With this in mind, I want to look at two examples of current health technology, robot-assisted surgery and telemedicine, how they have been received and their impact. Have these innovations improved health outcomes? For who? With what caveats?

Robot-assisted surgery

In 1985, a neurosurgical biopsy became the first robot-assisted surgery. Immediately, physicians were confronted with the idea that robots might perform surgeries better than people.

The sci-fi quality of robot-assisted surgery doesn’t settle with some but overall the technology has a large following. By 2000, the da Vinci surgical system became the first FDA-approved robotic surgery tool. The manufacturer of da Vinci reported in 2009 that 86% of surgeries for prostate cancer in the U.S. were conducted by robotic surgery systems. That is 73,000 operations, compared to less than 5,000 in 2001. 
   
Many deem its popularity the unfortunate result of aggressive marketing. Why unfortunate? There is little evidence that these operations are any better than the traditional laparoscopic approach, but the price tag for a system like da Vinci is just under 2 million dollars.

Not only do patients demand robotic operations, but hospitals are also incentivized to promote the high-tech surgeries in order to maintain a cutting-edge reputation, as well as to cover the exorbitant costs of the systems. Rather than empirical evidence, these incentives sustain the market for robotic operations.

When weighing the costs, the persistent mantra of “newer is better” may be fueling a mis-allocation of healthcare dollars.

Telemedicine

Through telemedicine, specialists provide patient services, such as x-ray readings and psychiatric consultations from remote locations. The practice has been applauded for its potential utility in developing countries. In 2010, the WHO reported that developed nations have the greatest number of established programs and programs in the pilot stage. That said, the WHO predicts the most growth to occur in low-income countries.

When compared with humanitarian aid, telemedicine may be a less invasive approach to health care provision. In particular, needs-strapped countries is where foreign experts often serve as consultants—while local health workers directly interact with and administer care to patients. This raises social issues regarding the use of telemedicine in developing countries. What are the implications of giving foreign doctors authority over local health?

In rural Mexico, a telemedicine program for breast cancer screening has become a feasible solution to their shortage of radiologists. Through this program, 30 sites send screening results via the Internet to eight centers where the images are read. In order for this network to function smoothly, rural centers have had to confront several infrastructure-related barriers such as poor Internet connectivity. In the past, some centers have resorted to saving their images to CDs and then physically transporting them to interpretation centers, but this workaround can create delays up to three weeks long. With these obstacles present in infrastructure, can developing countries surmount the initial start-up costs that telemedicine requires, and is this the best use of limited resources?

The Super Forces Jay Walker mentioned have the potential to transform the standard of care around the world, but unless we can push past the oversimplified “newer is better” ideology these Super Forces may only widen the health-wealth gap. Public health professionals have an ethical responsibility to act as a guiding hand to correct financially-driven market pressures that dictate design and development. We have an obligation to call for technology that will serve those who need it most: minorities and low-income families suffering from the poorest health outcomes. Rather than immediately accepting every new advance, we should monitor the effects of technology for specific contexts in both the developed and developing world.

When technology and equity clash, a robot probably isn’t the answer. Often, all that’s required is a human touch. 

Watch Jay Walker's Grand Rounds presentation below.

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