changing equations

The very microbes that helped humans evolve now make us sick

Our bodies have not changes as much as the standard for what constitutes a good microbe versus a bad one.

Between the mid-1990s and the mid-2000s alone, the likelihood of having a classmate with a food allergy increased by 20 per cent in the United States. In fact, over the past five decades, the incidence of all allergies and autoimmune diseases – caused by your body attacking itself – has skyrocketed. What could explain our sudden hypersensitivity to our surroundings and ourselves? Since evolution operates on the timescale of millennia, the culprits lie not in our genes but somewhere within our environment.

One thing that has changed in public health is our awareness of germs and how they spread. In response to that insight, over the past half-century our implementation of hygiene practices has spared us from debilitating infections and enormous human misery. But the new vigilance might have altered the development of our immune system, the collection of organs that fight infections and internal threats to our health.

The idea that too clean an environment might be harmful has been dubbed “the hygiene hypothesis”. The concept has been perverted by some to suggest that the less clean the environment, the better. But its meaning is different: it is not dirt that we are missing but exposure to certain microbes that normally contribute to the development of our immune system. “It’s not that we aren’t exposed enough to microbes but that we’re not exposed to the right types of microbes,” says the immunobiologist Ruslan Medzhitov at the Yale School of Medicine, also head of the Food Allergy Science Initiative at the Broad Institute.

So what has changed? In short, it’s the standard for what constitutes a good microbe versus a bad one. “Take bacterial species that increase nutrient absorption from food,” Medzhitov says. These were immensely beneficial at a time where you had to go days without eating. Today in the parts of the world with an overabundance of food, having such bacteria in your intestine contributes to obesity. “Microbes that cause intestinal inflammation are another example of what we call bad microbes because they induce [detrimental immune] responses. But in the past, these microbes could have protected you from intestinal pathogens,” he adds.

The most common such foes are helminths, commonly known as intestinal worms. While they have been eradicated in most of the economic West, their absence from our environment might be contributing to the increase in allergic and autoimmune diseases by diverting our immune system’s attention towards our food and ourselves. This is what Ken Cadwell, a microbiologist at New York University, contends. He is interested in better understanding Crohn’s, an autoimmune disease caused by our immune system attacking our gastrointestinal tract.

Worm treatment

Cadwell’s team discovered that the bacterium Bacteroides vulgatus causes reduced mucus secretion in mice, something that results in the condition. In collaboration with the parasitologist P’ng Loke, also at NYU, Cadwell then decided to treat mice that had Crohn’s disease with helminths, known to trigger mucus secretions in the intestine. And it worked! The two researchers identified that the ensuing establishment of Clostridiales bacteria in the gut cured the mice.

But would it work in humans? Loke collected stool samples from populations living in helminth-endemic areas in Malaysia before and after deworming treatment, and he noticed something intriguing. People from these regions had abundant Clostridiales in their gut before treatment and a lower incidence of autoimmune bowel diseases. After successful deworming, the protective bacteria disappeared, setting the stage for autoimmune illness to rear its head.

Yet treating humans with worms will not work as a public-health measure. Worm treatment is beneficial only for those Crohn’s patients with a genetic make-up causing reduced mucus-secretion and lacking Clostridiales bacteria. For everybody else, it is just a harmful infection. Now scientists are trying to better understand how to reap the benefits of worm therapy while avoiding its downsides. “I am more in favour of an alternative that gives the same [health] effect without having to give somebody a live parasite,” says Cadwell. “That would be ideal.”

Besides the change in our exposure to microbes, our modern lives include diets much higher in sugar, salt and carbs. Now a team from Harvard and Yale has discovered that even moderate increases in salt consumption trigger activation of immune actors, known as Th17 cells, especially prevalent in such autoimmune diseases as arthritis and multiple sclerosis, to name just two. “Recent studies found that if you have the right [genes], your likelihood of developing rheumatoid arthritis goes up 10-fold from the average risk in the population. But if you combine that with smoking, it leads to an increased risk of 100-fold. Now a recent study also showed that if you have the right [genes], you smoke, but you also consume a high-salt diet, the risk goes up 500-fold,” says the immunologist Vijay Kuchroo at Harvard, who did the work with his colleague, the neurologist David Hafler of Yale.

We are forced to conclude that the explosion of allergies and autoimmune diseases results from a mismatch between genes selected by pressures of our evolutionary past and the reality of modern life. While we have adapted in the past, we might not be able to adapt again by relying on biology alone. There is no going back – the old world is gone. To curtail the increase in allergies and autoimmunity, we have to evolve our social, political and scientific regimes, providing healthier food options at lower cost and improving our understanding of the underlying immunological mechanisms at play.

The writer is a graduate student in immunology at the Iwasaki Lab at the Yale School of Medicine.

This article was first published on Aeon.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.