Prevention is better than cure | Chris Fearne

At a glance, it seems as though Malta – and, for that matter, the rest of the world – may be on the cusp of a brave new digital health revolution. Not only is the ability to treat certain diseases and conditions improving thanks to the application of information technology… but with the sequencing of the human genome, the same technology can also be applied to prevent disease: thus radically improving the quality of life, while also alleviating the strain on the national health service.

Well, maybe not quite yet. The technology and data exist to make this a reality, but processing the information and using it as an effective preventive health tool is not, at present, a standard medical practice anywhere in the world.

Parliamentary secretary for health Chris Fearne, however, predicts it will be the absolute norm in as little as 15 years from now. “It’s an exciting time to be involved in the health sector,” he tells me in his office at Palazzo Castelletti, Valletta. “We are about to witness a sea-change: not just in Malta, but everywhere in the world.”

In Malta, however, this change may be more deeply felt. It is not just in bio-technology that things are changing… there have been a number of radical structural reforms announced of late: the construction of a new Gozo hospital and the refurbishment of St Luke’s, both to serve (inter alia) as learning hospitals for Barts Medical School… which in turn introduces competition in the medical education sector, where previously there was none. 

The health ministry has also entered into agreements with private clinics and hospitals to cut back on waiting lists at Mater Dei. 

The latest news concerns discussions with a Chinese biotech company – iCarbonX: a biotechT-IT venture co-founded by Dr Jun Wang, ex-CEO of Beijing Genomic Institute (BGI) – with the possibility of a private operation that as yet remains unclear.

The latter development is admittedly very interesting from a medical science point of view: we will shortly discuss the implications. But in the meantime, all these developments seem to point in a certain direction.

Are we looking at the thin end of the wedge here? Is the government slowly ceding more and more of its responsibilities for public health to private entities… and could this in any way impact the government’s stated objective to keep the service ‘free for all’?

“Let me start by saying this: my job, as parliamentary secretary for health, is to give the best possible level of health service, along three basic principles. Excellence, whereby we operate, to the best of our abilities, to achieve the highest standard level possible; accessibility, which means the service remains free for all Maltese and Gozitans, regardless of individual means; and also sustainability. All that we do is guided by those three principles. Excellence implies that the service is provided within good time; so we’re addressing the issue of waiting lists. We’re also ensuring that medicines are kept in stock, and that people are no longer accommodated in corridors....”

As for accessibility, Fearne asserts that his government is committed to keeping the service free for all. So the fly in the ointment, as it were, remains sustainability.

“Of course, all this comes at a cost. The service has to be sustainable. We believe that this can be guaranteed by the concept of medical tourism…”

In fact, ‘medical tourism’ was the topic discussed in our last interview, back in March. Fearne once again defines his government’s understanding of the term: that Malta develops a medical capacity beyond its immediate needs, so that – while Maltese patients continue to receive free service – the extra capacity can be used to attract paying patients from third country nationals (note: EU citizens are covered under various agreements between member states).

“Today it is becoming a reality. In the space of a year and a half things are moving forward. This should place us, for the first time ever, in a situation where the health sector no longer eats into the national exchequer, but will instead contribute to the economy…”

The current national expenditure on health, he adds, reaches around half a billion euros a year. 

“Most of that will continue to come from people’s taxes, naturally. Up to now, however, all of it has traditionally been financed by taxes. We are convinced – and it’s already happening – that a significant percentage of that cost will be covered by medical tourism. To give an example: the capital outlay for the construction of a new, 450-bed hospital in Gozo; for the extensive refurbishment of Karen Grech hospital, to turn it into a gerontology ward; and to refurbish and reopen St Luke’s… that capital amounts to around 210 million euros. It will all be put forward by our private partner, who will recoup the investment through paying patients from other countries…”

At the same, however, the junior minister is giving the impression that medical tourism is already reaping dividends, even though the new hospitals are not in operation yet…

He shakes his head. “No, what I said was that we are confident that it will reap dividends. And so are the investors, who were satisfied enough with the prospects to invest over 200 million euros. The real benefit for us, however, is not just that it helps to make the national health service sustainable. The additional facilities will also be used by Maltese patients… for free. They will improve the existing service, in line with our excellence goals.”

The real challenge, he continues, is more long-term. “We also have to look forward, and see how the medicines industry is going to develop over the next 15, 20 years. We want to position ourselves as leaders in this sphere, not followers. And this entails a radical overhaul of how we view the entire health sector…”

Fearne points out that, rather than a ‘health sector’, Malta’s service is geared mostly towards curing disease. “Up to now, although we claim to have made progress, the reality is that we don’t take ‘prevention’ as seriously as we take ‘cure’. This has to change. The medical profession is moving in this direction, and we need to start aligning ourselves to what is happening in the wider world.”

Ever since 2003, when the first complete human genome was sequenced, medical science has been evolving towards a situation where the risk of disease becomes easier to identify, and thus prevent. 

“The Americans call it ‘precision medicine’, we call it ‘personalised medicine’. But the future of medicine is to have treatment tailored for the specific medical needs of the individual.”

The Human Genome Project established that each individual has about 20,000 genes. “But there are 3 billion ‘base pairs’ – i.e., bits of genetic information – in every human being’s DNA. We already know that our health depends on three basic factors: genetics, the environment in which we live, and our lifestyle… and how these react with one another. We know the environment we live in; everybody is free to choose his or her own lifestyle… but before 2003, ‘genetics’ was the one thing we didn’t know enough about. Thanks to the genome project, it is now possible to determine exactly what the genetic health factors might be for every individual…”

While the original project was purely academic, since 2003 a number of private companies have harnessed the knowledge and put it to medical uses. “It is now possible to give these companies a DNA sample – blood, a hair, etc. – and within a day or less it would be possible to know your precise genetic makeup. We want to reach a situation where the genetic information can be matched with environment and lifestyle, to give the citizen comprehensive advice on how to avoid health problems. It’s like a prescription on how to prevent disease. Real, preventive medicine for each individual patient. That is where medicine is heading in the next 15 years. We want to be at the forefront…”

This may be exciting news for medical science, but it also sounds a little ominous. Helpful though genetic knowledge may be for doctors, it is also highly sensitive information. Among the concerns raised by the genome project, for instance, is what would happen if private genetic information were to be made available to insurers or employers. People with high-risk congenital issues might face higher premiums, etc… and there may be discrimination in other spheres. 

“Yes, and that is true also for all medical information, with or without genome sequencing: if an insurance company gets hold of your medical records, for instance. It is of course a concern for us, and we will be taking data protection very seriously. Naturally, the patient would have to give his full consent for the test to be done, and for the data to be used. There will be firewalls in place; we are already discussing what sort of data protection infrastructure we will need.”

One thing that will certainly be needed is considerably more information technology infrastructure and computing power than is actually present on the island. 

“To analyse those 3 billion base-pairs, you need more than just an ordinary computer. You need artificial intelligence. In the last few days we have had talks with one of these cutting edge companies, with a view to carrying out the research here in Malta…We want to become a world centre for personalised medicine. This is our vision, naturally; I’m not saying it will happen tomorrow. But we plan to be among the first countries in the world where a citizen can get this kind of fully personalised health service. The repercussions would be enormous… not only in terms of benefit to the patient, but also society as a whole. And the health sector in particular…”

Speaking of which: are there any estimates on what impact this system may have on recurring health expenditure? If we spend half a billion on curing diseases, what sort of cost reduction does he envisage as a result of prevention?

“We’re not really looking at this as a means to reduce costs. To us, the priority is to improve the quality of life of the individual. By preventing disease we would be able to invest more in other areas, yes, but it’s not the main goal. We’re looking at cases where people suffer from diabetes from age 30 or 40 onwards, for the rest of their lives. Or arthritis, from 55 onwards. Or cataracts. These are all conditions that affect your quality of life. Look how better that quality would be, if these conditions can be avoided…”

Having said that, he concedes that the way medical services operate will also be affected.

“No matter how good today’s medical service may seem in any country, it is ultimately always management-by-crisis. Someone gets sick, and needs emergency treatment. In the future the emphasis will be much more on prevention than cure. This way it really will be a ‘health service’…”

How close are we to this becoming a reality? What sort of investment are we looking at, and how will this venture – of which we haven’t really spoken yet – be financed?

“Wait, slow down. At this point we are only discussing possibilities. I’m not saying this company is going to set up here next week, or that we’ll be signing a memorandum of understanding…”

Have there been discussions with any other companies apart from ICarbonX?

“We have spoken to different people… but these seem to be the most cutting edge, and the most interested in working with us…”

All the same, assuming an agreement is reached to provide this sort of genetic sequencing technology as part of the national health service – how will the service-provider be chosen? Will the government issue a call for tenders or EOI?

“This would be foreign direct investment. If a company does set up here, it would be a private operation, undertaking its own research in Malta. We would enter an agreement to provide the service for Maltese citizens, at our cost. We might go for a private-public partnership, but at this stage, it’s too early to say.”

On the subject of PPPs: we’ve drifted away from the original question, which concerned reforms that increasingly seem to rope in the private sector. Isn’t this a case of outsourcing, and… going on the experience of other examples of outsourcing in the past… is there any danger that the ‘free-for-all’ model might be eroded?

“No, absolutely not. It remains a government commitment. But let me give an example regarding agreement with private hospitals. The way things were until today was that, if someone needed a hip replacement operation, he or she had only two options: to do it at Mater Dei, but they’d have to wait five or six years; or to do it immediately at a private hospital… and pay for it.

“Now, the way we are approaching this situation is twofold. One, to improve the service and efficiency at Mater Dei so that the waiting lists come down naturally; but two, we are also looking at working with the private sector, so that operations are carried out privately but paid for by the government. So we are encouraging the private sector to invest more and improve its own services, while providing the capital by paying for their services. Now, you might ask where all this money is coming from…”

Judging by earlier answers, I would guess medical tourism…

“Up to a point, yes. But it’s also a question of using money wisely. The government is committed to keeping the service free, so inevitably, it has to pay for it. We’re clear on this. But if we work with private institutions… instead of building a new hospital ourselves, the hospital would be built privately, using private capital outlay, and we would buy the services at the same cost as if we had built the hospital ourselves. Only without the cost of having to build it…”

Dr Fearne sees this as a win-win situation. 

“We’re not pushing people towards private healthcare, as we’re still paying for it ourselves. But we are using all the resources the country has to offer.”