Two of the most significant trends in health care are at cross-purposes: the boom in digital devices to prevent, diagnose, monitor and treat diseases, and the emerging recognition that environmental, economic and cultural factors are critical in affecting people’s health.
There is disagreement about the nature of the contradiction, and whether the two trends can be reconciled for the benefit of patients and the health-care system as a whole.
“It’s a big question,” says Jessilyn Dunn, a professor of biomedical engineering at Duke University, who helped develop a widely adopted framework for determining the safety and effectiveness of digital products.
The field is called digital therapeutics (DTx). It includes the use of sensors and algorithms to provide information and recommendations about people’s health. Think fitness trackers and smartwatches. Different devices collect different data, including biological information (heart rate, blood glucose, pulse); behaviour, such as the number of steps walked or hours slept; locations visited, both in the physical world and online (i.e., the websites viewed); and language, which is used to deduce emotions, mental illness and cognitive decline.
These data are continuously processed by algorithms. That’s the therapeutic component of digital therapeutics, says Jen Goldsack, CEO of the Digital Medicine Society, a professional organization working to advance the rapidly growing industry.
Therapeutic interventions from DTx fall into several categories, including recommendations for behavioural change; alerts about acute conditions, such as atrial fibrillation; and warnings of impending illness, such as Type 2 diabetes. Some of these interventions are packaged as comprehensive treatments for specific diseases, including Pear Therapeutics’ product Somryst, the first prescription DTx product for chronic insomnia.
Somryst is one of more than 50 apps for insomnia, each of which claims it can improve the length and quality of a person’s sleep. But a recent study in Science shows that factors outside a person’s control – especially air pollution, noise and light – adversely affect the ability to sleep.
Professor Dennis Raphael says this exemplifies the disconnect between DTx and the social determinants of health. Raphael, professor of Health Policy and Management at York University and co-author of Social Determinants of Health: The Canadian Facts, encapsulates the theory succinctly: “Health is primarily determined by a person’s living and working conditions: period.”
Poverty is the best predictor of a wide range of diseases, Raphael says, from cardiovascular disease and Type 2 diabetes to Alzheimer’s and arthritis. What’s more, the effects are compounded over a lifetime. “If you’re poor as a kid … poor as an adolescent … poor as an adult, then you have the highest risk of developing these diseases – and that’s independent of lifestyle.”
The best deterrent isn’t an emphasis on individual behaviour, but a change to public policy: “This is a constant battle in the trenches,” Raphael says. “Nobody wants to go near the fact that we make political decisions that affect who’s going to live and who’s going to die. Because ultimately, these diseases sicken, and they kill.”
Raphael’s research aligns with the work of Hannah Tait Neufeld and Chantelle Richmond, Canada Research Chairs in Indigenous Health and Environment at Waterloo and Western University, respectively. These professors add a historical element to the discussion.
“Health-promotion programs tend to focus on behavioural change at the individual level,” they note in a paper co-written with the Southwest Ontario Aboriginal Health Centre. The focus on individual behaviour persists despite “the growing base of evidence” that high rates of illness in Indigenous communities are rooted in the social determinants of health – especially the effects of being disconnected from the land.
“Not just physically removed,” Tait Neufeld explains, “but also removed from social connections – everything related to knowledge and culture and health practices” because residential schools took children from their families and communities.
The question then becomes: do digital therapeutics, by nature, contradict the fact that the environment – broadly defined to include social, political, economic and historical factors – affects people’s health far beyond what they’re able to change on their own?
No, says Duke University’s Dunn – not by their nature. And yet, she adds, the way digital devices are currently designed, marketed and used means “the onus is on the individual.”
Dunn predicts this will change as the industry matures, and digital measurements are linked with social and environmental factors. The very act of linking health data with environmental data – air pollution, income, access to healthy food and clean water, for example – could be used to shape policy.
“That’s when digital therapeutics can become a public-health modality rather than an individual-health modality,” she says. The limitation, then, wouldn’t be the technology – it would be the questions people ask.
The best deterrent isn’t an emphasis on individual behaviour, but a change to public policy.
Christo El Morr, a professor of health informatics at York University’s School of Health Policy and Management, is skeptical.
“If I’m trying to find out if people in a certain area are affected by a certain disease – or if education level is correlated with a health problem – it’s possible we could see that in the data,” he says. “But that information is already available.”
Increasingly sophisticated technology might make the data more “granular” and specific, but the broad trends are already known. “There’s a gap between the availability of information and the actions taken to change policy.” And DTx, he says, won’t change that.
Goldsack of the Digital Medicine Society sees the situation differently. She argues that technology won’t just fill current gaps, it will initiate an upheaval in society’s approach to health. In this new paradigm, policy and data can be more closely interwoven – but that’s not going to happen by chance: “I genuinely believe we have a three- to five-year window to get this right,” she says.
Duke University’s Dunn agrees: “Right now, the system is just giving us the ability to start doing the work that we’re interested in. But this is definitely not where we want to land.”
Where the system lands is being determined now by researchers, legislators, health-care advocates and the wider public.
“It’s all up to us about how we choose to deploy these tools in support of health care,” Goldsack says.