40 major milestones in healthcare
The sequencing of the human genome represents the most significant breakthrough in healthcare over the past 40 years, according to Modern Healthcare readers.
That achievement, capping a 13-year, $3 billion international effort funded by the federal government, drew the most votes from the 728 respondents to a survey that listed 60 healthcare milestones achieved since Modern Healthcare was founded in 1976. The survey asked readers to pick their top five choices from each of three categories: science and technology; healthcare delivery; and politics and policy.
The top choice of the Human Genome Project reflects a growing recognition of its importance to advancing medicine, something that wasn’t readily apparent when it was officially completed in 2003, said Dr. Francis Collins, who ran the project for the government and is now director of the National Institutes of Health.
“It’s not something that immediately changed healthcare,” he said. “Shortly after this process was completed, there were a bunch of responses that this was overhyped. It was the big fizzle.”
But Collins said that when it comes to technology, “Any major advances always have their consequences overestimated in the short run and underestimated in the long run.” And the tide has turned on the perception of genomics, reflected in its selection in the poll.
“I think it’s a sense of the historical nature of what this means,” Collins said. “For all of human history, we have labored without understanding our instruction book, and the human genome provided that. It’s like crossing a bridge.”
Collins was put in charge of the Human Genome Project in 1993, three years after its launch, when he took over as director of what is now called the National Human Genome Research Institute from famed genetics researcher James Watson. “It will find its way into the practice of medicine,” Collins said. “Maybe the case in five years (will be) that all of us being prescribed a drug for a condition will want to have our genome checked to see that it’s the right drug for us”—part of what’s being called precision medicine.
The sequencing of the human genome, chosen 416 times by readers, narrowly nudged out the next most important achievement, magnetic resonance imaging, which drew 403 ballots.
Neuroradiologist Dr. William Bradley, former radiology chair at the University of California at San Diego, began working with MRIs when they first surfaced during his residency in the 1970s. “The workhorse of medical imaging right now is MRI,” Bradley said. “There’s no radiation and you have superb soft-tissue contrast. . . . The idea of cutting things open to see what’s going on is a thing of the past.”
‘Touched by health reform’
The 2010 healthcare reform law, commonly known as Obamacare, topped the politics and policy category and ranked No. 3 overall, garnering 399 votes from Modern Healthcare readers. Placing second in politics and policy—No. 6 overall—was the Health Insurance Portability and Accountability Act, coming up on its 20th anniversary in August.
Both Obamacare and HIPAA have had broad effects on the healthcare industry, said Chip Kahn, CEO of the Federation of American Hospitals. They “created tremendous change on the delivery side through Medicare and Medicaid as well as the new plans that are available to people,” he said. “Every hospitalization is touched by health reform.”
HIPAA has remained relevant for nearly two decades because of its breadth and the advent of health information technology, which it sought to regulate at a time when computers were mostly used in the healthcare industry for claims processing and revenue-cycle management. HIPAA was designed as a framework, with Congress coming back later to craft details.
“But (it) never did,” said Kahn, who worked on the legislation as a top Republican aide on Capitol Hill. “It was too complex and difficult.”
Instead HHS agencies, empowered by HIPAA, implemented rules such as the recent switch to ICD-10 diagnostic and procedural codes. “It touches patients day to day, every day,” Kahn said. “For every transaction, there is something that crosses that rule.”
Wiping out smallpox
In healthcare delivery, the category winner was the eradication of smallpox, ranked fourth overall with 320 votes.
After nearly two centuries of public health efforts that started when English physician Dr. Edward Jenner began promoting vaccination in the 1700s, smallpox was officially declared dead by the World Health Organization in 1980. The elimination of smallpox in the U.S. had been largely achieved in the 19th century, but as recently as the 1950s, tens of millions of people elsewhere in the world were infected with the virus each year.
Dr. William Foege, who headed the Centers for Disease Control and Prevention from 1977 to 1983, began battling smallpox as a consultant to a Lutheran health mission in eastern Nigeria in 1966 and continued the fight at the CDC in the last endemic areas—India, Bangladesh, and finally, Somalia in 1977.
“We’re now going on about half a century without a single case,” said Foege, now a consultant to the Carter Center and the Bill & Melinda Gates Foundation.
Identifying the first case of acquired immune deficiency syndrome, or AIDS, placed second in the healthcare delivery category and fifth overall. The mysterious outbreak was first reported in the CDC’s Morbidity and Mortality Weekly Report in July 1981.
At the time, Dr. James Curran was chief of the research branch at the CDC, conducting trials on hepatitis B, which was then “an epidemic in the gay community.” The CDC began receiving reports of a spike in an advanced form of Kaposi’s sarcoma, pneumonia and other opportunistic infections that resulted from severe immune-system suppression.
Curran was named to head up the CDC’s investigative task force. The agency dispatched investigators to 18 cities to look back five years for similar cases.
“We found more than 150 cases and they were increasing rapidly,” he said. While there was a strong link to gay men, one of the early victims was a woman and a few others were self-injected drug users. Another was an infant.
“A lot of us thought it was due to a new virus or a modified virus, but a lot of other people didn’t think that,” Curran said. “They thought it might be due to immune overload. At first, people didn’t think it was in the blood supply, but then three cases surfaced of hemophiliacs who were not gay and not drug users. That was repeated by people with a single transfusion. It became quite clear this was due to a new virus transmitted through sexual activity, or through the blood, and not restricted to gay men,” Curran said.
The CDC in 1983 issued prevention recommendations, even before there was a known cause, Curran said. That year, researchers at the Pasteur Institute in Paris published findings that identified a virus associated with AIDS risk. In 1984, a team headed by Robert Gallo at the National Cancer Institute published its work, establishing the link between the human immodeficiency virus and AIDS.
Since then, an estimated 35 million people have died of AIDS, said Curran, co-director and principal investigator at the Center for AIDS Research and dean of the Rollins School of Public Health at Emory University in Atlanta. Another 10 million people are receiving lifeextending drug therapy, “but there are 20 million people who don’t have (the drugs) and 2 million people are getting infected” each year.
“The highest priorities now are curative therapies and (finding) a vaccine,” Curran said.
Craig Venter, left, president of Celera Genomics, President Bill Clinton and Dr. Francis Collins, who led the Human Genome Project, gather for a teleconference on June 26,2000, to announce that the International Human Genome Project and C el era Ge no mic shave both completed an initial sequencing of the human genome.