Brave New Millennium Part II - A Look at the Future

At the end of the 21st century, according to an article by Steven Sharfstein MD appearing in an issue of the Archives of General Psychiatry, one third of the gross domestic product in the US will be spent on health care. High-tech gene health centers - the hospitals of an earlier age - will provide gene therapy, biomedical engineering, and organ replacements to all those in need, but many of the basic services will take place at home or work.

The horrors of managed care will be a thing of the past, to be replaced by the free market and the government working together in a form of enlightened partnership. All physicians will be the employees of one of several gigantic health care corporations, which will compete for patients enrolled through the government.

Many of you reading this will be around to see these predictions come true, according to the article, for Americans will live to an average age of 105 years, and people celebrating their 130th and 140th birthdays will not be uncommon.

Mind you, we will be blowing out the birthday candles with the aid of genetically-engineered replacement lungs, not to mention almost all our other organs

Only our brains will be irreplaceable. Hence the continued need for psychiatrists, whose certifications will be in neuroscience, medical psychiatry, psychotherapy, and social psychiatry. The neuroscientist/psychiatrist with a combined MD and PhD will be the most highly specialized (and highly paid), an expert on the human genome, brain imaging and mapping, the differential use of neurochemicals, and the application of high technology.

Supercomputers programmed with the entire sequence of the human genome and different functions of the parts of the brain will perform much of the diagnostic chores, with sophisticated guidelines for biological and nonbiological interventions. Psychiatric hospitals will be a thing of the past, many medications will be available over the counter, and prescription drugs will be introduced via high-tech delivery systems into the brain.

That is, assuming there will be any patients left to practice on. In another article in the same issue, Robert Michels MD predicts that thanks to genetic embryo screening, "DSM-IV classics" will be rare. Rather than focusing on treatments for mental illness, psychiatry will be organized to help us fulfill our human potential.

However the future shapes up, both authors appear to view the present in terms of the bad old days. According to Michels: "Psychiatry treat[s] psychological disasters, but offer[s] little to improve the lives of the rest of us." And in concluding his article, Sharfstein observes: "Human progress comes in many forms. In the year 2099, medicine and psychiatry will have made advances that make the prior 200 years of psychiatric care seem crude, quaint, and in some ways absurd."

Ah, if only we could believe all that. True, medical science can work wonders, but we have a long way to go before it proves to be a boon to all of mankind. An editorial in Medscape General Medicine provides us with some sobering statistics:

Around 1.3 billion people on the planet live in absolute grinding poverty, on less than a dollar a day, this despite a world economy that has doubled in the last 25 years.

Only sixty percent of the 4.4 billion people living in developing countries have access to sanitation, a third have no access to clean water, and about 20 percent lack access to healthcare of any kind.

The wretched of the earth are not confined to the third world. Life expectancy has dropped precipitously in eastern Europe, especially in Russia, where a man can expect to die 15 years sooner than his western counterpart. Meanwhile, in the UK, the mortality rates between the professional class and unskilled class increased from a two-fold difference in 1970 to a three-fold difference in 1993. And in the US, more than one in four children under the age of 12 have difficulties obtaining all the food they need.

For the poor, ill health is tantamount to disaster. According to the editorial:

"By definition, poor people have very few reserves and may be forced to sell what assets they have, including land and livestock, or borrow at high interest rates in order to deal with the immediate crisis precipitated by illness. Each option leaves them more vulnerable, less able to recover their former condition, and in greater danger of moving down the poverty spiral."

The editorial does not mention mental health, but we hardly need to use our imaginations here. In many third world nations, the nearest pharmacy may be hundreds of miles away, but access to deadly pesticides are readily available and loom large in suicide. Back home, it is often a case of insanity rules, from the many thousands of mentally ill who wind up in the criminal justice system to the absurdities of HMOs to state-run systems that simultaneously force treatment and deny same.

And so we must look to a brave new world through the murky prism of the present. New gene technology and other breakthroughs may soon make it possible for the entire human race to be saner, smarter, and live longer. But don't hold your breath waiting for these or any other miracles to happen. The science part is easy. The social equity part - that will take time.

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Robert Michels: DSM-IV classics will be rare.