Stéphane Gayet : On the plan epidemiological, despite all the progress made in disease surveillance, it is only just possible to glimpse the general trends in diseases that are already in circulation; but the forecast of emerging epidemic phenomena is still very utopian. Because the emerging epidemic phenomena are essentially of infectious or toxic origin.
Is about infectious origin, we know at least one thing: emerging diseases are above all zoonoses, in other words infectious animal diseases which accidentally pass to humans and then develop there by becoming autonomous. Severe acute respiratory syndrome (SARS) and Ebola virus, but also other older zoonoses such as the plague and yellow fever, evolve in the form of epidemic foci that appear and then disappear without being able to really anticipate them. The primordial reservoirs of these infectious diseases are animals (zoonoses), humans can become a secondary reservoir during an epidemic episode, allowing the development and extension of this episode. As for Lyme disease (borreliosis associated with other infections), it is also a zoonosis, but which has become endemic (permanent). There are other zoonoses, which are not responsible for epidemics, but only for sporadic (isolated) cases, such as leptospirosis.
Regarding the possibility of new emerging infectious diseases, Public Health France and all the organizations attached to it (Regional Health Agencies in particular) have an efficient and well-established vigilance system. The alerts work pretty well and quickly.
It’s the same with emerging diseases of toxic origin : their source can be food (it is then industrial food) or water, essentially. Industrial food can also be the cause of cases of food poisoning (it is either a microorganism most often bacterial, or more rarely a microbial toxin alone, that is to say having contaminated a food in which the source microorganism is no longer present).
In short, all that can be said is that there is a constant expectation of new epidemics. Despite all the regulations and vigilance, climate change and the endless race for profit make them very likely.
Regarding epidemic and strictly human infectious diseases such as measles, it is vaccination that should help stem the spread of the epidemic. In the case of epidemic and zoonotic infectious diseases for which there is no vaccination, such as Lyme disease, the progression will continue, in the absence of sufficiently effective prevention and the very large number of infected animals.
As far as healthcare professionals are concerned, the technological boom is continuing rapidly and this is practically a problem. Indeed, we constantly invent and create new devices to explore and treat diseases. These devices are true marvels of miniaturization and performance. Their use is more and more gentle and painless, so that one is tempted to use them in very young, very old or very fragile people. These new medical devices are presented at medical and surgical congresses. There is an emulation between doctors and surgeons, each having the desire to own and use this or that device before his colleagues. These innovative devices contribute in part to the reputation of this or that clinic, of this or that practitioner. The companies that design, manufacture and market them have an impressive sales force: they put forward the idea that these new devices will save money, thanks to very clever and well presented reasoning. However, it is often the opposite, for a variety of reasons: most of these innovative medical devices generally contribute to an increase in healthcare costs, whatever one may say.
It’s easy to understand that health spending only increase. Of course, in this economic circuit, it is the private market companies that are financially profitable. But beware: it is out of the question to deny the interest of the progress in terms of quality and safety of care allowed by these new devices; these advances are obviously important and sometimes enormous. However, it is clear that these new medical devices are generally increasing health care costs.
The National Objective of Health Insurance Expenses or ONDAM, set up by the 1996 Juppé Plan ordinances, is a tool intended to control health insurance expenses. This is the target for spending not to be exceeded on city care, hospitalization and medico-social care. It is voted each year in Parliament when the Social Security Financing Law (LFSS) is voted. ONDAM is very close to 200 billion euros annually. Its natural tendency is to increase annually by 4%. The LFSS seek to maintain this increase at around 2.5%.
About special, the development of health apps for mobile phones will intensify. This is a booming field where many startups compete. Obviously, this way of managing one’s health is something that appeals to a lot, especially since there has been for a number of years a strong current of distrust of the medical profession as a whole.
In terms of developments pharmaceutical, it is easy to understand that research is directed towards the most profitable substances. The president and CEO of the huge global investment bank, flagship of international finance, had himself declared: “In pharmaceutical research, it is not profitable to invest in the research of substances that cure the sick, but rather in that of substances that keep them alive without healing them. We can see that the financial objectives are not health objectives. This is the reality principle. Consequently, it appears quite clearly that pharmaceutical research is directed much more towards anticancer drugs, immunosuppressive and immunomodulatory drugs, than towards antibiotics. We should therefore expect in 2020 new anti-cancer drugs and new immunosuppressants or immunomodulators, and very little or no new antibiotics, which we really need. It’s perfectly logical. This is even more so when you take into account the fact that a new antibiotic expires relatively quickly due to the appearance of bacterial resistance.
In addition, we should also expect the launch of new products to slow the progression of Alzheimer’s disease: several products are under development. The negotiations for their taking over by the Health Insurance will certainly be tough. Because it seems clear that all these new drugs will be very expensive.
Regarding developments regulatory, the trend to allow non-doctor health professionals to perform acts hitherto reserved for doctors should logically continue (pharmacists, doctors). Obviously, the fairly privileged situation that doctors have long enjoyed in the health care system should continue to erode. Vaccination against flu by pharmacists and advanced nursing practices are just two examples among many. Jurisdiction to issue a death certificate is likely to follow, as well as other measures. The trend to withdraw drugs from the market, either without sufficient proof of efficacy or with a narrow therapeutic margin (MTE) will of course continue: each week, several drugs are removed from the French pharmacopoeia supply. The therapeutic range is the difference between the effective dose and the toxic dose of a drug.
The French health system has long been oriented mainly towards curative care. By making compulsory 11 instead of 3 vaccines in children, the Ministry of Health has shown its commitment to prevention. This movement should also be confirmed, since prevention is in all respects more profitable than curative care, especially that given at an advanced stage of an illness.
Neurodegenerative or neuro-inflammatory diseases (Alzheimer’s disease, Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis, etc.) have been awaiting progress for years. This is still the case with chronic Lyme disease, whose knowledge of the mechanism, diagnosis and treatment must urgently progress. This is also the case for inflammatory bowel disease or IBD (Crohn’s disease, ulcerative colitis, etc.).
It is an opportunity to point out that the challenge of medicine in the coming years will be to understand and prevent or treat chronic diseases that are poorly understood, those diseases that represent the future of medicine, given that most acute illnesses are preventable, curable or have a spontaneously favorable course. And cancers are also part of these chronic diseases which are still very insufficiently understood because they are particularly complex.
Teleconsultation is particularly likely to experience strong development in 2020: it is both comfortable for both parties and applicable to many pathologies or health conditions. A dozen operators are already offering liberal physicians a turnkey teleconsultation solution, with costs amounting to 15 or 20% of the price of the consultation. From a distance, you can order additional tests, seek specialist advice, make a secure prescription, and many other medical procedures.
In the same order, so-called dematerialized prescriptions will become generalized.
The number of so-called conventional hospitalizations will continue to decrease in favor of day hospitalization or as well as hospitalization at home (HAD). HAD certainly has a bright future, because, like day hospitalization, it is both pleasant for the patient and their loved ones, and a source of savings for Health Insurance.
But e health is still diagnostic aid software for doctors, databases concerning recorded and listed side effects of medicines and also continuing medical training at a distance, without forgetting of course the medical record. shared or DMP, real digital health book (there are, in addition to the official version of the DMP, private versions from startups).
The doctor-patient relationship will evolve a lot due to the development and deployment of these new tools which prove to be efficient and very useful. We will evolve towards a kind of partnership. Patients will sometimes know more than their doctor about their chronic illness, this is fatal. This is one of the evolutionary trends indeed, it must be accepted and taken into account in the medical management of a sick person.