Dr Irengbam Mohendra Singh
At precisely the moment I’m thinking of writing about precision medicine, Ojha Chakree Tombi comes to my mind. His name was Salam Tombi. Chakree (argumentative) was a fond nickname given by the hoi polloi in Imphal. He was a school teacher and a very good hockey player. He used to argue a lot with referees while playing hockey. He was a bit like the American tennis player McEnroe, who used to argue a lot with the referee at Wimbledon, often saying “you’ve got to be joking.”
Chakree Tombi was we boys’ hero, as he was a kind of a macho man. I met him sometimes at the Uripok office of L Joychandra, the Editor of Prajatantra Daily. He was once standing in front of the Congress Office near Rup Mahal Theatre. Soldiers from the 1st Manipur Rifles (all Gurkhas) were dispersing a large crowd of protesters with fixed bayonets from around the area near Kangla gate. We were all running, but he refused to run and sat down. He got rifle-butted a few times before he moved.
Tombi became an MP in Delhi, during my medical college days. I once met him at his flat in South Avenue, New Delhi. He has been to Wellington Hospital for government employees (Now RML Hospital) for something or the other. He was shocked that there were so many disciplines in the practice of medicine. He was telling us: eikhoigi doctordine, shamdagi houraga khongee khujin faoba yengbajatni. Meaning, doctors in Imphal, will treat everything beginning from the hair on the head to the toenails.
I was also surprised 30 years ago, when I found out that there were at least 10 sub specialities in ophthalmology in large London hospitals. Sub-specialities focus on certain diseases, or various parts of the eye individually. Paediatric ophthalmology is a big subspecies. Normally in provincial hospitals, there are only general ophthalmologists, who treat everything related to the eyes.
Two years before I became a medical student in 1955, President Eisenhower suffered a heart attack in the middle of the night (heart attacks often occur about this time). He was staying at his wife Mamie’s family home in Denver. His physician Dr Snyder injected morphine and other drugs, non-specific for a heart attack or for his falling blood pressure and irregular pulse. He then told Mamie to snuggle with her husband in bed to keep him warm. Eisenhower slept till noon the next day. Then Dr Snyder called a cardiologist to do an electrocardiogram. Later, the president went by car to a hospital, where he was confined for seven weeks in bed and chair with limited physical activity.
This was the sate of medical care for a patient with heart attack, who was No.1 man in America. There was very little else doctors could do. Since then, technology has improved so much along with a variety of medicines at the disposal of a doctor. A specialist in internal medicine in America, can now prescribe 11,700 drugs.
The current trend for a patient with heart attack or stroke is to seek immediate medical help within 3 hours, where available, so that doctors can inject drugs to dissolve clots in the arteries, and correct dangerous heart beat disorders. That can be done at the scene, or in an ambulance by highly trained paramedics on the way to a hospital, before it scars the heart muscles.
In late 1960s when I was a trainee Medical Registrar, to be a specialist, patients with acute heart attacks, were no more confined to bed. They were allowed to sit up and go to the washroom, and were discharged home much sooner.
Advances in western medicine with unparalled technology have been pushing the boundary of science, especially after 1960’s. Life sciences’ sector is spearheading this technological rush. Across the UK, life scientists are pioneering treatments, progressing advanced therapies and genomics, using digital technology and artificial intelligence.
‘Life sciences’ is a new discipline that’s rapidly advancing. It can now be studied at Manipur University. Though biology remains the centrepiece, it involves the study of the structure and function of living things from molecules to entire ecosystems, and their applications in research, industry, and healthcare.
Treatment of high blood pressure or hypertension, previously called “Hard Pulse Disease” had no suitable medications until 1958, when a drug called chlorothiazide was discovered. It reduced blood pressure (BP) by making the person to pass a lot of urine by the kidney, and thus reducing blood volume. Until very recently, hypertension by definition, was a BP that exceeds 140/90.
In November 2017, many Americans were shocked when American heart experts issued new guidelines for lowering blood pressure to what they think as minimum standard for diagnosing high hypertension, which they defined as: (1) stage 1 high blood pressure as 130/80, which was previously considered within acceptable limits, and (2) stage 2 high blood pressure as 140/90. They were based on the favourable prevention of stroke, heart attack, loss of vision and kidney disease.
This is very well in research. During my medical practice, it was very hard to reduce BP even to 140/90, using three-drug regime.Precision Medicine (PM), (Stratified Medicine) is a medical practice that is ‘customised care’ with medical decisions, practices, or products that are tailored to the individual patient. It was formerly called Personalised Medicine. PM, in fine-tuning in the treatment of eye diseases for individual patients in America, is currently very successful.
PM is an emerging style for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person. It’s like tailoring a suit to fit a particular individual. This approach will enable doctors and researchers to choose accurately which treatment and prevention strategies for a particular disease will work in which group of people. It’s contrary to the conventional one-size-fits-all approach, in which disease treatment and preventions strategies are developed for the average person. Though at the moment, the practice of PM in day-to-day healthcare is limited, researchers are working on it to expand to many areas of health care.
In the US, Barrack Obama in his January 2015 State of the Union address, announced the launch of the most ambitious Healthcare initiative called the Precision Medicine Initiative (PMI). It was a mission to usher the US into a new era of medicine where patients will enjoy individualised and tailor-made treatments for various ailments.
In Western Europe, healthcare science works together with life sciences in hospital laboratories, such as clinical pathology laboratories in specialists hospitals, transplant units, and Public Health. UK is the biggest investor in precision medicine (1 billion pounds). To enrich research in this field, UK is stretching out to researchers in India. The life sciences sector is one of the UK’s best international performers, contributing 5.2% of the UK’s export in 2016. The diverse sector includes medicines, surgical supplies and equipment.
In the UK, Liam Fox, International Trade Secretary, said in March 2018: “with a combination of top universities, research institutions, global life sciences companies and increasing government support, the UK is a fantastic place for the sector to invest, which is why we are now in the top three of life sciences hub globally. UK regions like Liverpool, are also attracting investment from life sciences inward investors working on flu vaccines and the development of new medicines.”
Life sciences are accelerating PM, while they are helped by the fastest growing Information Technology, which redefines what is possible for life by researching in things like genome sequencing and speeding up molecular dynamics performance, connecting patients’ care teams and data. Already the amount of existing and new data flowing through today’s healthcare model is enormous and growing. The result is better patient outcomes with improved provider and payer resource utilization.
Prof Dame Anna Dominiczak, Head of the University’s College of Medical, Veterinary and Life Sciences in Glasgow, said in March 2018 that “Precision medicine is already capable of revolutionising healthcare, by bringing the prospects of earlier diagnosis, more effective treatment, cost saving, and better patient outcomes. The University of Glasgow is leading the way in this medical revolution with collaboration at the heart of its success.”
She added: “For precision medicine work, the collaboration of three parties are essential: (1) It requires molecular technologies developed by academic researchers. (2) Molecular technologies are to be combined with electronically held patient data. (3) We need industry in the form of small or large companies, to transfer new discoveries into treatments that benefit patients.”
The area where personalised medicine is benefitting patients at the moment, is ophthalmology that has been an early adopter of personalised medicine, (partly because it has two eyes for comparison). It has a potential to revolutionise the speciality with the application of gene replacement therapies for some inherited monogenic eye diseases eg green-colour blindness and primary open-angle glaucoma. It already promises a better management of the complex age-related macular degeneration that causes blindness in old age.
It’s said, in any country, sophistication in individualised approaches in medicine requires in the first place, advances in genetics, and disease stratification that relies on phenotypic and genetic assessment, leading to molecular diagnosis. Individualisation also encompasses all aspects of patient care, including nursing care, conventional therapies, and trials of novel DNA-based therapies.
The writer is based in the UK Email: firstname.lastname@example.org Website: www,drimsingh.co.uk.
Dr Irengbam Mohendra Singh