In his late eighteenth century work, An Essay on the Principle of Population1, scholar Robert Thomas Malthus2 predicted that the world’s population would eventually outstrip its ability to produce food, resulting in chaos and population collapse, which later became known as a “Malthusian Crisis”3. Today, despite a global population of nearly 8 billion, a jump from a figure of 900 million in 1800, it seems that society is managing to stay ahead of the curve, with virtually all modern starvation a result of civil war, oppression and corruption, rather than a glaring global disconnect between consumption and production.
Over the years, Malthus’ theories have been applied to other topics with mixed responses. That said, there are good arguments to be made in relation to his thoughts on environmental damage, the elimination of indigenous peoples, extinction of other species4 and global warming.
Consider his theory from the perspective of healthcare and disease burden. The population keeps growing5, especially in the developing world. The aged population is rapidly increasing in the medically developed world6. The burden of non-communicable disease is rising everywhere7, and it looks like we’re failing miserably at keeping up with the disease burden. Was Malthus wrong about the capability of the agricultural and financial support structure to keep up with hunger, but correct in his warning about the inability of the global medical industrial enterprise to provide adequate care for disease?
Let’s take heart disease as an example, by 2030 the annual global burden of death from ischaemic heart disease, stroke and hypertensive disease is predicted to increase by over 20% to more than 19 million8. And, unless the trend is reversed, the cost burden is predicted to exceed 1 trillion USD per year by 20359.
In this case, what we need to consider is if we can use technology to prevent heart disease when it is preventable, and to stave it off or reduce it when it is not.
One way to think about a group of patients from the standpoint of health and disease is a pyramid, with those most severely affected at the top, the healthy at the bottom, with those at varying stages of risk and severity in the middle and moving upwards. Everyone knows we should focus on those at the top of the triangle but it’s just as important that we move deeper into the triangle.
A mix of devices, data collection and smart analysis can help. Our task? To reach those one level down from the top – let’s call them the “identified, but not comprehensively managed” with cardiovascular disease – and keep them away from the top, ensuring compliance and encouraging lifestyle changes. We should also be using data to identify those with a diagnosis of cardiovascular disease that has not been documented10. If these individuals aren’t documented, it’s difficult to keep them from moving up the pyramid. We must also use data to identify those at highest risk of developing cardiovascular disease at some point. By leveraging genomics and other physiologic and clinical indicators, we can delay the onset of disease and possibly minimize its impact when it manifests. Finally, we must work to provide those fortunate individuals currently at the base of our pyramid with tools to keep them healthy for as long as possible.
Most non-communicable diseases, such as cancer and cardiovascular disease, are most prevalent in the medically-developing world, where populations are growing. We’re also facing significant increases in both oncologic and neurologic diseases in the rapidly aging, medically-developed world. We are doing okay with the most severely affected in the medical first world, but not as well prepared in countries where care is not adequate to meet the challenge presented by these patients, much less dealing with those at lower levels in the triangle in either context.
The good news? We have many of the tools we need in hand now. The question is whether or not we will increasingly incentivize their use by providers and the general public, and apply them on a time course that allows us to avoid a Malthusian healthcare crisis.