Imagining the future of healthcare
“The past is a foreign country: they do things differently there.” L.P. Hartley, Balliol 1915.
The past may be a foreign country, but the future is even more so — and it’s one for which there are no accurate tourist guides either. What’s more, if the recent political upheaval (in the UK) has taught us anything, it is that predicting the future is risky business.
But researchers at the University of Oxford have a long history of writing the future of medicine, from the discovery of penicillin to testing an Ebola vaccine. Whatever time of the day you are reading this, it is quite likely that an experiment or study brewing right now in a lab in Oxford is going to influence what healthcare looks like in 50 years’ time.
So what might change healthcare in as dramatic a way as penicillin? What might worry our grandchildren in the same way that Ebola, Zika and the obesity epidemic worry us now, and what might be the answers to these worries? What will the future of medicine look like?
Here are four quite different visions of the future of medicine, from four researchers spread across Oxford University. All of them have different answers, but they all work at the cutting edge of their field: a position which just might give them a glimpse of what is around the corner. Come with us as we find out what they see.
When Nicola Fawcett sees people, she sees ecosystems on legs.
“I think in future, we won’t be treating humans as just humans”, she said during our conversation amongst the skeletons of the past at the Oxford University Museum of Natural History. “Instead, we’re going to be treating people as multispecies organisms — colonies of both man and microbes.”
This is a perspective based on years of studying the human microbiome — the collection of tiny microbes that would call us home. They live on us and in us, and there are a whole lot of them: based on a count of bacterial versus human cells, we are more bacteria than human. As a clinical research fellow within the Modernising Medical Microbiology (@ModMedMicro) research group, Nicola’s work day frequently involves cycling around Oxford picking up samples of fresh poop provided by volunteers for the ARMORD study, which aims to find out exactly what antibiotics do to our gut bacteria. “The anaerobic bacteria are quite weedy and start dying as soon as they’re exposed to air”, she explained, so she is the proud owner of what her research group calls the poo phone: it’s like the bat signal, but it instead lights up when volunteers call in to report a fresh sample. (Apparently, parents of young children and health-care workers are the group most comfortable with providing these ‘samples’, and so make up a large proportion of study volunteers.)
But apart from the great potential for grossing people out and for puns (another microbiome study is called RePOOPulate), there is a serious purpose here.
It’s one that Nicola bumped into quite by chance: she trained as a medic at Oxford University, and towards the end of her degree, she and her then boyfriend wanted to do a rotation in the same speciality, which meant that they’d be competing against each other. Nicola graciously allowed her boyfriend first dibs, and at the suggestion of someone at a conference, picked acute medicine as her speciality.
The boyfriend is long gone (Nicola is now married to another Oxford researcher, who works in medical genetics), but the acute medicine placement turned out to be an eye-opener: medics in this sub-field work with very ill patients in places like the A&E department, and they are at the sharp end of medicine. The strong emphasis on research combined with clinical practice within medical training at Oxford University meant that Nicola always thought that she would be quite likely to do research. “I just thought that getting some clinical practice under my belt first would give me a better idea of what might make for an interesting research question,” she said.
Nicola remembers the first time she saw the importance of gut bacteria, as a first year Oxford University medical student. “We suddenly had people who were 25 years or so come in, who were completely well, perhaps with a high white cell count and a fast heart rate as the only things that were a bit odd. And two days later, they were dead,” she said. This was the start of the 2006 outbreak of infections of Clostridium difficile infections.
C. diff, as it is almost affectionately known to microbiologists, is an oxygen-hating bacterium that is found pretty much everywhere in nature, especially in soil. 2–5% of the adult population have it in their colon too, and it is a tough critter: when things get difficult, C.diff forms spores that can survive in extreme conditions, such as heat — and your standard hand sanitizer.
Whilst most of the time C.diff appears to be fairly harmless, sometimes it can go rogue, producing toxins that cause bloating and diarrhoea, and later, severe abdominal pain. If not treated, people infected with rogue C.diff can die, having been poisoned by bacteria in their own gut.
What is now understood is that one of the things that allows these rogue bacteria to take hold is recent antibiotic treatment. “It turned out that most of these patients had had strong antibiotic treatment a few weeks before”, recalls Nicola, “and it had effectively wiped out most of their ‘healthy’ gut bacteria.” C.diff is resistant to many antibiotics, and with the competition from other bacteria helpfully wiped out, it could fully colonize the gut. “It then changed its behaviour: it started producing toxins which irritated the colon, eventually perforating it — and people died.”
These events a decade back were the seeds of what eventually became the ARMORD study, currently being carried out at the John Radcliffe Hospital in Oxford. The ARMORD study uses genetic sequencing to identify the unique complement of bacteria found in each of their volunteers (and while it’s not yet of diagnostic value, volunteers do get their own personal gut microbe profile in return for their poop). Researchers are particularly interested in comparing what gut bacteria look like before and after the volunteers have had a course of antibiotics. And short of an endoscopy, the best way of getting an idea of what is in someone’s gut is getting your (very well-gloved) hands on their poop.
“It’s a glamorous job, but someone has got to do it”, Nicola says wryly. What the job involves is putting a pea-sized amount of the poop into a test-tube with some glass beads and some saline solution, and shaking the test-tube really hard. This breaks open the cell walls of the bacteria in the poop, so that the DNA is out in the open. The rest is (relatively) easy: with a bit of purification, washing, filtering and getting rid of the human DNA, you’re left with just the DNA from the bacteria (with some bits of the viruses and fungi and ‘god knows what else’ which also like to hang out in the warm, cosy confines of our colons).
This DNA can then be sequenced: the sequence of the four-letter ‘alphabet’ that makes up DNA can be read out, and this sequence is different for each species. “We read about 1–2 million base pairs (the DNA alphabet) to identify the species of bacteria to find the bits that are identical to the known sequences of different bacteria: we might find 10,000 hits for E.Coli for example, 3,000 for another bacteria, and so on.”
But this genetic sequencing approach is pretty powerful, and it can also do a lot more than merely cataloguing what’s in a given gut. “We can also say, ‘Aha, this bit of DNA looks like the gene that confers resistance to the antibiotic tetracycline, and this one to penicillin.’ So you can use this approach to study antibiotic resistance not just to the bacteria we’re able to grow in a petri-dish, but to all the bacteria we can find in a poo sample. We’re very interested in tracking what happens to these genes when you’re recently taken antibiotics: does it change the bacteria in your gut, and are your bacteria now more likely to have antibiotic-resistance genes?”
A separate study also plans to track hospital patients who have been given antibiotics over the next 10–15 years, to find out if specific patterns of gut bacteria can predict one’s risk of developing infections in the future, especially drug-resistant ones. “We know for example that antibiotic use as a child can be linked to the risk of Crohn’s Disease 10–15 years later, so it’s really important to do these long-term studies,” says Nicola.
But she thinks that microbiologists are just the first explorers stumbling into terra incognita, since they’ve had to deal with antibiotic-resistant bacteria. Even then, they are only just waking up to the importance of one’s microbes to our wider health.“We now realize that we’re in constant communication with the microbes within our body, and they influence everything from how our immune system works to the hormones that control our appetite: is it me or my microbes that chose to eat that hamburger?”
The Zen-like answer to that question is that the distinction is an illusion: there is no spoon, and it is sometimes impossible to tell where the microbes end and where we begin.
Post C.diff, clinicians are already closer to this enlightenment than they were 10 years back — it is now part of the received wisdom that antibiotic use should be limited to cases where there is a clear need — and the ‘if in doubt, don’t disrupt the healthy bacteria!’ advice implicitly recognises that the patient in front of them is a multispecies entity.
But there are other frontiers to cross. “Have you heard of faecal implants?” Nicola asks encouragingly. These turn out to be exactly what they sound like: you take a sample of faeces from a healthy person, you mulch it up and give it ‘up the back’ or via a nasal tube into the stomach of someone who is really desperately in need of good bacteria, such as someone with a recurrent C.diff infection. It is a risky procedure, but is also currently the most effective treatment for such recurrent infections, because it seems to change the profile of gut bacteria in the transplant recipient.
Probiotic drinks, with high levels of ‘good’ bacteria, claim to do the same thing much more hygienically and they are big business. But their effectiveness in changing your personal gut ecosystem is still questionable. “It’s like parachuting in 10,000 monkeys into a Siberian tundra, and thinking that will turn it into a rainforest,” says Nicola. “But I think we’re going to get much better at these probiotics, though we’re not quite there yet.”
As the cost of sequencing a personal microbiome falls, microbiome testing might become more like a kidney function test: a routine test carried out on patients informs what treatments they’re given. And this doesn’t just include antibiotics: a patient’s response to cancer treatments also seems to be affected by what bacteria they have in their gut, as does the response to treatments for auto-immune diseases such as arthritis.
“Clinicians are used to thinking of bacteria as the bad guys, and we think that the perfect world is a sterile, clean place,” says Nicola. “I think this will seem very, very old-fashioned in the future.”
When Dario Salvi and Carmelo Velardo see people, they see jet engines prone to rare but catastrophic failures.
Dario and Carmelo are both post-doctoral researchers at the Institute of Biomedical Engineering at Oxford University. The IBME is a good place for anyone interested in charting the future of medicine: it brings together clinicians and engineers to solve problems like how to produce cheap artificial limbs and other prosthetics in developing countries (answer: get people to make them themselves) and how to deliver drugs exactly where they are wanted (answer: bubbles. No, really).
Dario and Carmelo are part of Professor Lionel Tarrassenko’s group, and I speak to them at Dario’s desk, where they frequently complete each other’s sentences and answer questions for each other. They’re also both from backgrounds which might seem unusual in medicine: Dario is a former telecoms engineer, and Carmelo is a computer science engineer.
“As a telecoms engineer, you can either go off and work for something like a bank and make loads of money,” says Dario. “Or you can go off and do something which is a bit more socially useful.”
‘Useful’ is definitely a good way to describe one of Professor Tarassenko’s most well-known research projects, which found a way to predict when jet engines are likely to fail.
“The problem with jet engines is that they are very reliable machines”, says Carmelo.
It’s a statement that exemplifies the slightly unusual view of the world that data engineers seem to have. But it is a statement that makes sense, when you see the world through a data engineer’s eyes. “We want to study failures to find out how they happened, but when there are very few failures, the task gets very difficult,” Carmelo explains.
The second problem is that on a rare occasion that a jet engine fails in operation, the results can be catastrophic. So how do you solve a problem which you don’t have much chance to study, but which needs to be solved because when it does happen, several hundred people can potentially die?
It turns out that the answer lies in an arcane (unless you are a data engineer) data analysis technique known as novelty detection. Instead of waiting for a jet engine to fail and then combing through the wreckage to find out what went wrong, this approach collects data about the performance of jet engines flying normally. Sophisticated computer programs then analyse reams of this data to learn what counts as ‘normal’ for a jet engine — and they then flag up patterns of data which are abnormal.
The beauty of this method is that not only does it get around the problem of not having enough data to really understand rare failures, but also that it can potentially predict that a jet engine is about to fail, long before anyone operating a plane notices anything amiss.
It’s also an approach that can be transferred to any complicated system where you can collect enough data — such as people. “The next challenge was patients: they’re exactly like jet engines,” Carmelo says, to much head-nodding from Dario. “They don’t ‘fail’ very often, but when they do, it’s catastrophic, and the patient might die.”
The intensive care unit (ICU) at the John Radcliffe Hospital is currently testing the benefits of treating patients like jet engines, at least when it comes to data analysis. This was a project initially borne of frustration: “It was pretty much impossible for us to even get data from patients in hospitals”, says Carmelo. “Nurses recorded vital signs (such as heart rate, blood pressure, temperature, breathing rate) from a patient onto a piece of paper. Then doctors would come around and look at this piece of paper and do their own bit of ‘novelty detection’ to find out when a patient needed attention.”
The venerable patient chart at the foot of the bed has been around for many years, but it does have its problems: the piece of paper might get lost, an alarming trend might not get picked up until a doctor next comes around, and the lack of digitisation makes it difficult for data engineers to access this data.
One solution to these problems is SEND: System for Electronic Notification and Documentation, which replaces paper charts with wireless tablets. The project is led by Dr Peter Watkinson, an intensive care physician at Oxford University Hospitals NHS Foundation Trust, and SEND is already being used in everyday clinical practice at several hospitals in Oxfordshire. Patients wear a wristband with a bar code, and scanning the bar code brings up the patient’s records on a tablet. Clinicians can then add to these records, with the result being better clinical care for patients.
But this digitisation also means that data engineers can now start analysing patterns that emerge from the 17,000+ daily observations that take place in the Oxfordshire hospitals participating in the project. “We can start identifying important patterns: for example, is there a consistent pattern of changes in vital signs that happen before a patient has to be transferred to an ICU? Is there a pattern which distinguishes patients that have a long stay in the ICU from those that are able to leave quickly?” Carmelo says.
These patterns are not obvious from simply looking at charts of vital signs such as heart rate or temperature. But by using computer programs to detect novel patterns or patterns that distinguish patients with different outcomes, these systems can start potentially to predict what is going to happen to a patient, well before it actually does.
This approach of analysing continuously generated data to find patterns is pretty powerful: as if predicting the future is not enough, it also brings personalized medicine within reach of anyone treating a patient. At the moment, for example, heart rate or blood pressure measurements which fall outside a set threshold count as abnormal, and contribute to an early warning sign score which clinicians use to decide who needs immediate attention. “But say my blood pressure is higher than Dario’s all the time,” says Carmelo. “Or maybe my body temperature follows a pattern during the day that is normal for me, but might be really abnormal for someone else. But with enough data, computer-based machine learning approaches can work out what counts as a normal pattern for measurements for you personally.”
Carmelo and Dario’s ambitions are not restricted to changing how patients are treated in hospitals: they are currently testing out apps that help patients with diseases such as congestive heart failure build up a pattern of what counts as normal and abnormal for them, by getting them to use the apps daily in their own homes. And this is just the beginning: “Step 2 would be integrating genetics data into our computer learning algorithms, to make their predictive power even better”, says Dario. “I don’t think this kind of personalized medicine is too far off: I think it will be here in the next few years.”
In some ways, this future is already here: Dario and Carmelo are in collaboration with Stanford University on an iPhone app called My Heart Counts, which monitors activity levels and measures of cardiovascular fitness. The app is free and the 50,000 citizen scientists who have already taken part are encouraged to participate every day for as long as they can.
The hope is that the same data crunching which can predict when jet engines are about to fail will also be able to find patterns of factors that can predict cardiovascular health. And genetic data is already in the mix: “Some of the people who are using this app have also used 23andMe (a commercial company which carries out paid-for DNA analysis), and we’re asking them if we can have access to this data too,” says Dario. The aim is to add genetic information to the data mix, to find out how different genetic backgrounds interact with physical activity to influence cardiovascular health.
Both Carmelo and Dario envision a future where our smartphones, fitness monitors and even our houses and cars constantly collect data streams about our health to predict our future, in exactly the same way that data from jet engines is constantly analysed to predict when they might fail. “There is no reason that we can’t put the algorithm that we’re using in the SEND project in a mobile device for a patient to take home,” says Carmelo. “There is no reason that a nurse or a doctor is needed to monitor a patient’s health: patients can do this themselves, and they become the carriers of their own health data.”
In this future, the health data collected on our smartphones would tell doctors what counts as normal for us, and there would be no one-size-fits-all early warning scores. In a future reminiscent of the film ‘Minority Report’, where the police are alerted about crimes before they happen, our smartphones might also warn our GPs when the pattern of our health data looks worrying.
And it won’t just be our smartphones either: “There is already evidence that motion detectors (the sort used for automatically turning on lights) can pick up early signs of depression or dementia, since people with depression or dementia tend to move less than they used to,” points out Dario. He sees a future where we have many intelligent devices around us — at work, at home, in the car — and they all collect data about our health, with car steering wheels containing heart rate sensors, for example.
“We do have to solve lots of problems before we get there: how to get all of these different devices to talk together, how to make sense of the avalanche of data these devices will produce, and perhaps most importantly, how do you get people to change their habits, when the data suggests that what they are doing is adversely affecting their health,” says Dario.
I say that this sounds very much like in the future, Big Brother will always be watching us. Carmelo is sanguine about this: “Big Brother is already here. Whenever we install an app on our smartphones, we’re already agreeing to share a whole host of data about us — our names, ages, email addresses, locations, our contacts. If big corporations want to, they can build up a pretty complete picture of us from this data, and people are happy to share this data just to play a game, for example.”
“The health data that we work with is obviously more sensitive, and you can see the ethical problems that might arise if, for example, insurance companies say that they want access to it.”
It’s an issue that regulatory bodies like the FDA are currently grappling with, and Dario and Carmelo work with the guidelines of the National Institute of Health Care and Excellence (NICE) to make sure that the apps they are developing undergo a thorough ethical review: “The target group of our app is among the first group to assess these issues, and then the apps will also get assessed with crowd-sourced public opinions. Finally, an expert committee will also assesses them,” says Carmelo. But this takes time, while commercially provided apps speed ahead. “If you want a new FitBit app, for example, you can get it within minutes. But if you want an app that works with your doctor to monitor your diabetes, we need to do a proper randomized control trial to show that the app is beneficial. It is for the benefit of the patient.”
These checks and balances are necessary, and researchers are mindful of privacy as well; for example, both the SEND trial and the MyHeartCounts app strip out individual patient details when analysing their datasets to find patterns. But for a generation that has grown up with smartphones and sharing their personal lives online, perhaps these concerns will seem very old-fashioned. And perhaps we’ll finally be able to justify being glued to our smartphones as if our lives depended on it, because in the future, they just might.
When Hagan Bayley sees people, he sees a very large collection of very small parts.
Hagan Bayley is Professor of Chemical Biology at the Department of Chemistry at Oxford University, and he trained here as a student. He is now back in a shiny new building at the heart of Oxford University’s science campus on South Parks Road: some of the most venerable buildings here are dedicated to Chemistry, and the first chemistry laboratory at Oxford dates back to 1860 (it’s still there: an extension to the building now houses the undergraduate teaching laboratory, and there can’t be many undergraduate chemistry labs in a Victorian Gothic style). The Department of Chemistry at Oxford University has produced four Nobel laureates, including Dorothy Hodgkin, still the only British woman to win a Nobel prize.
With its large expanses of glass combined with old stone, the new Chemistry building somehow manages to look very futuristic and very old at the same time, which is quite appropriate for Hagan’s work: like many of the early Chemistry pioneers, Hagan and his group have had to build their own equipment, but his research career has been devoted to biological structures that are unimaginably small. In his world, a picolitre (a trillionth of a litre) is a fairly large quantity, and much of the work he does is at the nanoscale, where things are a thousand-millionth of a metre or a litre.
In case you think that this is an arcane subject area unlikely to have an impact on the real world, you should know that Hagan’s work led to the ability to carry out DNA sequencing using a mobile ‘lab’ that’s a little bit smaller than a playing card: technology which this year enabled the decoding of Ebola virus variants in a field hospital in West Africa.
In the not-too-distant future, his work is likely to enable the 3D printing of made-to-measure tissues and, one day, organs.
Hagan’s main interest is membrane proteins: complex, multi-part proteins that are part of a cell’s ‘skin’, the thin membrane that separates a cell’s insides from the outside. He is particularly interested in ion channels, membrane proteins which span the cell’s skin, and which selectively let electrically charged particles (ions) into and out of the cell. If you want to find out where the brain or the heart’s electrical activity ultimately happens, these are the structures to look at. The flow of ions is what ultimately lies beneath the complex patterns of electrical discharges that are so central to the brain and the heart. It is this flow of ions which is the basis for the electrical activity that is so central to the workings of the brain and the heart.
“We wanted to record the current across a single ion channel in a convenient miniaturized system,” says Hagan. To do so, they had to embed a channel in a membrane separating two nanometre-sized droplets (really, really tiny drops of water). The minute current was measured by placing an electrode in each droplet. “But it occurred to us that if we could get two of these droplets together successfully, why not hundreds or thousands or tens of thousands?”
Hagan’s research group had brought together the two droplets in the original experiment just by (an extremely steady) hand. But, painstakingly positioning hundreds and thousands of droplets was going to be a massive undertaking even for the most dedicated of graduate students. “That’s when we considered 3D printing.”
3D printing ‘ink’ is more usually plastic, something which is a lot more robust than the tiny, water-filled droplets that Hagan wanted to use. But one of his graduate students, Gabriel Villar, developed custom-made hardware and software which enabled the group to use these droplets as the ink in a 3D printer. Hagan’s group could now print these droplets in nearly any configuration that they could imagine.
Water droplets nestled together are, at best, an abstract idea of biological tissue, rather than anything like the complex interactions between cells found in our bodies. But 3D printing with these droplets to form an artificial tissue-like material opened up a whole new area in synthetic biology. “There are really two ways to ‘do’ synthetic biology”, explains Hagan. “One is to completely reprogram cells: suck out their DNA and put in a new genome. The other is to build new cells from biological parts. A logical extension of the latter is to build synthetic tissues, but there has been very little work along these lines.”
By embedding membrane proteins between their water droplets, Hagan’s group could get the cells in their synthetic tissue to carry out one of the most basic of biological functions: they could make different cells communicate with each other. For example, they could transmit an electrical signal from one side of the tissue to the other, and by getting the droplets to cooperate, they could cause their printed material to fold in interesting ways.
All of which is very cool, but what use is this artificial tissue-like material?
Hagan is sanguine: “A lot of things start off by just being a very cool idea: the sequencing of the human genome was greeted by a lot of protest about it being a complete waste of money, and that most of the genome was rubbish anyway, with not that many protein-coding genes. MRI scanners were initially greeted with scepticism, with claims that clinicians would get more useful information from observing what patients could or couldn’t do, like button up a shirt.”
Which is not to say that he isn’t full of ideas about how this artificial tissue could be used: “Our idea is to make tissue substitutes, and couple them to a living material. For example, an artificial tissue like ours could be used to slowly release a drug or a hormone. Or they could be used in wound healing: these tissues could provide a scaffold for regenerating nerves to grow along, helping re-establish connections between nerves after spinal injury.” If successful, these uses would be life-changing: a bio-mimetic slow release of insulin could get rid of the need for insulin injections in diabetics, and successfully knitting together injured nerves would mean that many people currently confined to wheelchairs would be able to walk.
But Hagan’s group also played around some more with the ‘ink’ in their 3D printers: the next step was to insert living cells into the water droplets, to make printed tissues. This is still a long way from true biological tissue, but printed tissues can already produce proteins, and they can be used to test drugs too.
“We can also now print using living cells, to make pieces of biological tissue,” says Hagan. At the moment, the research group uses lab-grow cells as the printing ‘ink’, but they have grander plans. “Eventually, we’d like to get into personalised medicine, and use cells from individual patients. We might be able to take tumour cells from an individual patient, print them, and test different chemotherapy drugs on them to find which one will be most effective for that particular patient.”
This kind of testing on patients’ own cells can already be done by culturing their cells in a petri dish, but the jump from 2D to 3D makes a big difference: “Tumour cells don’t live on culture plates: they live in complex, three-dimensional environments within the body. The more truthfully we can mimic this form, the more accurate our testing is going to be.”
“Drugs will work differently on 3D tumours than on cells in dishes, and we see this with bacteria too: they can respond to certain antibiotics in culture on a plate, but the antibiotics may not work in an actual infection. Sometimes, this is because a bacterium is living in a niche in the body, where it is almost another organism, expressing very different genes.”
Hagan also thinks that this more truthful mimicking of real biological systems also has the potential to replace some tests currently carried out in animals: “It won’t replace animal testing completely, but we definitely think that this approach can reduce it.”
The next challenge is to print living cells at higher densities, and to print them out without damaging the cells. “We also want to be able to have cells divide and grow as they would in real tissue. We also want to have multiple printing heads and print out two or three different kinds of cells at the same time, so that we can obtain patterns of cells that resemble what you’d find in natural tissue.”
“We can already do this on a small scale. This is quite a competitive area. But we think we have superior technology, and we’ve founded a company called OxSyBio to develop our methods faster.” (Like Oxford Nanopore, the company which commercialised the sequencing technology that enabled the decoding of Ebola virus variants in the field. OxSyBio was established with the help of Oxford University Innovation, Oxford University’s technology transfer company.)
With living cells as the printing ‘ink’, the aim is to make printed tissue, with real-world applications: personalised drug testing, providing ‘patches’ for repairing organs (useful for surgery), and ultimately, replacement organs with printed components.
Hagan doesn’t think this future is unimaginably far off: “I think that printing cells that can be used to test drugs will come very quickly, in the next few years. Printing small tumours using a patient’s own cells will also likely become quite routine soon. “
“Printing pieces of tissue which can be used in surgery is trickier, but I don’t see why the technology to make this possible won’t be developed in the next 5–10 years, though regulatory permissions may double or triple this time.”
But completely building a new organ? “Well, the pancreas is going to be much easier, than say, the brain, but I certainly see that happening in the coming decades.”
3D printing is potentially a cheap technology: once a printer gets going, it can crank out multiple copies of whatever you want, and genome sequencing shows just how rapidly costs drop as a technology becomes adopted.
“It depends on the world we want to live in,” says Hagan. “But we’ll definitely reach a time where an artificial heart is cheaper than a car.”
When Daniel Freeman sees people — well, he doesn’t think there is such a thing as a person separate from their environment.
Daniel Freeman is a Professor of Clinical Psychology and NIHR researcher at the Department of Psychiatry, and he says: “Our minds and bodies are inseparable from the environment, and many mental health issues are linked to how people behave in specific environments.”
Getting people to change their behaviour is a very old problem, but Daniel’s work uses very new technology to bring about these changes: he recently showed that it’s possible to use virtual reality (VR) simulations to change the way that people with severe paranoia approach the world. And he thinks that this is just the beginning: “VR can give all of us a chance to practice how to be our very best,” he says.
Daniel thinks that 800 year old University is the right place to bring about this particular vision of the future. “Oxford University has really led the way in finding the best evidence-based treatments for a variety of disorders related to anxiety,” he said, pointing out the research done at institutes within the University such as Oxford Centre for Anxiety Disorders and Trauma (OxCADAT). “So it isn’t surprising that it’s also here that we’re coming up with ways of getting these treatments to as many people as possible.”
This is a viewpoint based on the fact that despite being treated a bit like the ugly step-sister when it comes to getting the world’s attention, mental ill-health causes more suffering in most developed societies than physical illness, poverty and unemployment. In Thrive: the power of evidence-based therapies, OxCADAT’s Professor David Clark explains why this is both unjust and a false economy, and how getting tried-and-tested therapies to the people who need them can turn lives around.
Researchers at Oxford have been developing many ways of getting therapies to people other than the usual route of a therapist, such as the True Colours mood-tracking app, and now, virtual reality.
By persuading people with severe paranoid delusions to drop their ‘defence behaviours’ (such as avoiding eye contact) in a virtual reality simulation, Daniel and his research group got these patients to re-learn that the situations they feared were actually safe. While it’s unclear how long-term these changes are, just the extent of the change is quite startling: “It was really quite remarkable,” says Daniel. “Nearly half of our sample had no paranoid delusions after 30 minutes of the VR treatment, and the effects transferred over to the real world, such as going to their local shop.”
It’s an approach that could theoretically work for many other conditions besides paranoia: “Someone who is socially anxious, someone who finds it hard to be in a roomful of other people, someone who has got problems giving speeches or presentations in front of other people, someone who is afraid of heights, someone who had a problem saying no to that one last drink — all of these issues have to do with how someone interacts with an environment,” Daniel explains.
According to Daniel, the key to really changing a person’s thinking and behaviour is to first understand what factors maintain that behaviour. For paranoid thoughts, this includes a series of defence behaviours which are difficult to tackle in real-life. Even if people with paranoid thoughts end up interacting with others, they do it behind a self-imposed filter: they might keep their eyes down, or keep to the edges of the room. This is why simply exposing people to real-life situations that they fear, so that they may learn that they are safe, doesn’t always work: “The trouble is that people tend to think that they just about got away with being in a situation because they did all of these things: they don’t think ‘huh, nothing bad actually happened’,” says Daniel.
But having people practice dropping these behaviours has a pretty impressive effect, such as reducing paranoid thought in a sample that had previously proved resistant to drug treatment. So why not have a go at doing so in real life?
“It’s a big, big step to confront your fears in real life,” explains Daniel. “It’s much easier to do it in virtual reality.” Paradoxically, VR works precisely because people trying it out know that it’s not real, but it feels fully real to anyone trying it on.
The second advantage of VR is that it allows researchers a level of control that doesn’t exist in the real world: if you’re scared of heights, you could start from a really low height and slowly work your way up to the Empire State Building, and in the same day if you wanted.
The participants in Daniel’s experiments could also try things that would have been pretty difficult to try in real-life: “In our trial, we could get participants to almost go toe-to-toe with people, in a way that would be impossible in the real world. But that’s the way they really learnt that it was okay to approach people,” says Daniel.
VR might also be a way to tackle another problem that plagues mental health initiatives: not enough therapists. “We now have the right treatments for lots of mental health conditions, but there are too few therapists, and there are issues with controlling the quality of therapy provided,” Daniel explains. “VR is potentially a great way of getting high-quality, standardised mental health treatments out there to many more people.“
Daniel sees a world where VR headsets will one day be as common, and as cheap, as games consoles, and where the therapist will be in your living room. “I think in the years to come, every home will have a VR headset,” says Daniel. “Why wouldn’t you? If you’ve got, say, a conference speech you’re worried about, why not practice it on a VR headset first?”
VR won’t just be a good stand-in for real-life: it could also be a way for therapists to put on their head-set and interact with people in their own home. “We aren’t too far off from having therapists as computer characters appearing in the VR world right now,” explains Daniel.
VR could also be used for assessment, replacing the current retrospective assessment that happens during a therapy session. “We currently rely on the patient’s recollection of what happened, or we get them to fill in a questionnaire to get a sense of what sort of problems they are having,” Daniel says. But VR could give therapists a much more direct feel of what the problem is: “ We could find out what sort of situations trouble your patient, and put them there with a VR headset, right there and then, and see how they do — say a combat veteran’s PTSD is triggered by being on a street, we could find out by getting them to put on a headset, and putting them on a virtual street.” The group already collects data about physiological measurements such as heart rate, as their participants navigate the virtual world; this data could provide a much clearer picture of what triggers a person has, compared to their memory of what bothers them.
Nor are the uses of VR restricted to those with a clinical condition: in this virtual reality future, all of us could access personalised therapy tailored to what we find difficult to do. By allowing us to do things, albeit in a slightly unreal world, VR is moving therapy away from talking about things to doing things. “Instead of hours of talking, our therapists already do things like go out in the real world with a patient to try doing the things that are problematic”. VR makes this much easier, and allows the possibility of tackling the small things that niggle all of us. Perhaps you’re not very confident, or have low self-esteem? You can walk in a VR world where you experience lots of positive interaction, something that has already been shown to increase self-esteem.
“VR is just taking off,” says Daniel. “But I think in future, it could potentially help all of us be the best version of ourselves.”
Appreciating your gut bacteria, constantly tracking information about your health, getting a custom-made heart printed for yourself and using virtual reality to be the best you can be — if he were alive now, the Oxford alumnus and poet L.P. Hartley might be forgiven for thinking that the future is not just a foreign country, but a whole new world.
But these are just four of the many, many potential futures that Oxford University researchers are working on right now (nearly 20 researchers were initially interviewed for this article). For more on how Oxford research is changing the world, check out our science and art blogs.
Credits
Written by Charvy Narain (@charvynarain).
What next?
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Produced by Christopher Eddie, Digital Communications Office, University of Oxford.
