Fighting disease

Through time, humans have evolved to survive and beat devastating infectious diseases

But we never really genetically overcame bacterial infections through evolution.

It’s easy to feel our survival is under threat from new and emerging infectious diseases that are going to wipe out the human race, or at least end our current way of life. The recent outbreaks of Ebola in West Africa re-ignited our interest in pandemics and reminded us of our potential frailty in the face of an overwhelming enemy.

With so many microbes capable of hijacking and destroying us, how are we as a species still enduring?

Humans are unique in the world. We are avid “collectors” of infectious diseases acquired from our environment throughout our evolution.

We share with our invaders a need to survive and propagate our genes. Infectious pathogens, such as bacteria and viruses, are parasitic – they have to find and infect a susceptible host in order to maintain themselves and propagate. Therefore, it’s not really in their best interests to kill us. Our relationship with pathogens is shaped by our capacity to evolve genetically, to modify our behaviour, or to force the pathogens to evolve so that we all survive.

Viruses such as influenza replicate and spread to new hosts before the original host gets sick (with influenza symptoms such as a sore throat and sneezing), meaning the parasite can survive and thrive in new hosts.

On rare occasions the death of the host is necessary for the pathogen to reproduce. One example is trichinellosis (also known as trichinosis), which is caused by eating undercooked or raw meat from animals (usually carnivores and omnivores) infected with a worm (nematode).

To survive in the host the worm constructs a capsule around itself to avoid the immune system. The immature worms in the meat cause muscle weakness and paralysis, and eventually death, in the host. This means the victim is defenceless to predators that may come and gobble it up, thus giving the worm a new host to infect.

This is an old disease that we tackle either by avoiding eating meat (possibly the reason some religions avoid eating pork), or through cultural adaptation such as overcooking.

How we’ve adapted to win the fight

Evolutionary pressures through Darwinian selection, survival of the fittest, constantly shape life on Earth. This innate ability to adapt has enabled humans to develop defence mechanisms to counter some of the most devastating pathogens.

Malaria is a parasite of red blood cells that is estimated to have caused 429,000 deaths in 2015. When malaria became a human disease (it is thought to originate in primates) is unclear. One thing that is clear is that it emerged long enough ago for humans to evolve innate defences.

Sickle cell mutation is a potentially fatal blood disorder seen mainly in Africa. This mutation in a haemoglobin gene (responsible for red pigment in blood cells) is one of a number of genetic traits that actually protect against malaria. People who have this genetic mutation are protected against malaria and thus likely to reproduce and pass on their evolutionary advantage.

Sickle cell anemia is a mutation in response to malaria infections where red blood cells assume an abnormal rigid sickle shape. (Image: Ed Uthman/Flickr)
Sickle cell anemia is a mutation in response to malaria infections where red blood cells assume an abnormal rigid sickle shape. (Image: Ed Uthman/Flickr)

A second genetic mutation that protects humans against malaria affects an essential enzyme for red blood cell function. But individuals with this mutation may also develop life-threatening anaemia (deficiency in the number or quality of red blood cells) due to the destruction of red blood cells as a side effect of treatment with some modern anti-malarial drugs.

Perhaps the most significant and wondrous part of the evolutionary machinery that enables the human race to keep one step ahead of the pathogens is the major histocompatibility complex or MHC. The MHC – proteins on the surface of our white blood cells – evolved along with the vertebrates (animals with a spine), which makes them our oldest defence mechanism.

We have different types of white cells: mobile ones in the blood (lypmphocytes) and resident ones in lymph nodes (macrophages). When there is an infection the macrophages gobble up the bugs and “present” proteins from the organism on their surface like signals.

The lymphocytes containing MHC molecules that recognise this protein bind on. (Our immune system has memory cells that are produced after vaccination or past infections so we can remember how to fight them next time.) The lymphocytes then produce chemicals that recruit more lymphocytes to help. These multiply and you end up with a “swollen gland”.

Our body’s ability to “remember” past infections is one of the reasons the entire population of London didn’t perish during the Black Death. MHC molecules are passed on to our offspring, which explains why we have such a wide variety of these molecules. When a disease enters a population for the first time it always more lethal than subsequent introductions because some people are now immune, and people have been born to the survivors.

Not all pathogens make us stronger

Not all co-evolution leads to changes in human genetics, especially if there is no impact on our ability to procreate. Human tuberculosis is a chronic disease that continues to plague the world with little evidence that humans have developed any ability to resist infection. This is interesting because it is likely to have co-evolved with us from Neolithic times.

We will continue to face new and emerging diseases. So far our capacity to adapt and respond has served us well. But some scientists believe humans are no longer evolving due to the removal of many selection pressures, most importantly things that cause premature death.

The question is whether we are up to the challenges posed by what comes next. Perhaps the most pressing issue facing us now is that bugs seem to be evolving faster than we can create things to kill them – known as anti-microbial resistance.

The spectre of life without antibiotics is terrifying given we never did “overcome” bacterial infections through evolution. Instead we used our ingenuity. Our future will reflect how well we exercise our collective intellect and will to dodge this bullet.

This article first appeared on The Conversation. This is the second article in a four-part series looking at how infectious diseases have influenced our culture and evolution, and how we, in turn, have influenced them. Read the first part here.

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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.