Positive Outcomes From an Infectious Disease Crisis

My life in public health has taught me that no crisis should go unexploited for its potential to improve health care delivery. For example, publicity about an outbreak of gastrointestinal infection has the benefit of serving as a strong reminder to restaurants of the importance of ensuring safe food handling practices. An outcome of the COVID-19 pandemic has been the rapid progress made in putting patients — not providers — at the center of health care. This resulted in an increased focus on patient-centric care. In the words of visionary health expert Eric Topol, “the patient will see you now.” Core to this transition is the availability of enabling technology as mundane as self-administered rapid diagnostic tests or as sophisticated as using drones to deliver medicine in rural settings.

Putting the patient at the center of health care is not a new idea. Self-testing for pregnancy has been around for 50 years, home monitoring of blood pressure has been around since the 1980s (almost exactly 100 years after the technology was invented), and packaging that promotes medication adherence has been around nearly as long as oral contraceptives have been on the market. In no condition has the complicated dance between the development of patient-centric technology and the health care system relinquishing control of their care been more dramatic than in diabetes. Finger-stick blood glucose tests were first developed in 1965, glucose monitors in 1970, and yet self-testing did not become common until the 1980s. Ironically, since 2006 the linkage between sensoring and drug administration in the form of insulin pumps is increasingly getting both providers and patients out of management decisions.

The infectious disease sector, however, has been slow to embrace self-testing and management. On one level this is understandable because infections can be rapidly fatal, and overuse of antibiotics can have grave societal consequences. Furthermore, diagnostic tests are rarely perfect and thus must be interpreted in the context of expert judgement that considers other data; a positive HIV test does not have the same significance among elderly nuns as it does among a young and sexually active population. Such subtleties complicate the job of the Food and Drug Administration (FDA) that must ensure the tests we take are accurate, which in turn creates regulatory hurdles that inevitably delay the introduction of new technology.

The double whammy of an airborne infection that overwhelmed the capacity of health care facilities forced a change. In response to COVID-19, there has been an unprecedented innovation in the development, approval, and deployment in areas such as self-testing, telehealth, and remote patient monitoring. As a pediatrician who runs a practice in Seattle told me, “we had an 18-month plan to introduce telehealth, but with COVID-19 we did so in 2 weeks.” It is gratifying to think these advancements, and the recognition of their value, will have durable effects.

This is increasingly happening in infectious diseases. In the US, patients can now test at home for COVID-19, HIV, and sexually transmitted infections. When digitized in the context of other data, artificial intelligence (AI) holds the promise of democratizing highly accurate tests so that diagnostic acumen once only available from a highly trained clinician can now be provided anywhere, anytime at any scale. An important data stream to integrate is the clinical manifestations of infection. For example, fever has been measurable for a century but can now be digitized in ways that increase its accuracy and clinical value. It can even be aggregated at a community level to get near-real time information on the epidemiology of transmissible diseases such as influenza. And the ability to easily monitor an individual’s temperature over protracted periods of time is revealing novel insights into its significance in illness and in health.

I am particularly excited about the implications of our newfound ability to unobtrusively measure cough. Despite being one of the most common reasons people seek medical care, it is not currently measured at all, akin to treating fever without a thermometer. The situation is made more woeful by the lack of diagnostic tests for chronic cough, which are most frequently caused by common conditions such as gastroesophageal reflux disease, asthma, and sinusitis. Without a test the diagnosis is made by serial empiric trials of antacids, inhalers, and decongestants — the results of which are never actually measured. As a chronic cougher myself, I can attest that this can be experienced by the patient as “take some [over-the-counter] medicine and don’t come back.”

But with acoustic AI it is now possible to monitor cough unobtrusively and continuously. We are surrounded by high quality microphones that can provide the appropriate data stream. AI algorithms, such as that used by Hyfe, can monitor these data in a way that preserves privacy and identifies cough. Sophisticated algorithms trained on millions of sounds can now turn smartphones, watches, and speakers into “Fitbits for cough” that monitor cough over time or eventually “Shazams for cough” that can help identify its cause.

Another interesting aspect of patient-centric care is how, in many instances, it has been patients leading the charge for advancement of remote health monitoring and how providers and health care systems are following. I suspect this will be true with cough quantification and was surprised how few of the pulmonary disease physicians at the American Thoracic Society’s recent conference in San Francisco expressed an interest in quantifying their patients’ cough. But as a patient, when I contracted COVID-19 I made sure my provider saw the graph of my daily cough count shooting up to 800 per day as I made my case for why I needed Paxlovid.

As an aging provider who increasingly finds himself as a patient — I get it. Finding the right balance between doing what we know works and what we think will work better is hard. It’s not a realm for pirates whose attitude is “first we must break it.” In my opinion, the silver lining to the very dark cloud of COVID-19 is that we can innovate faster. And any innovation that puts patients at the center and in control of their health care should be prioritized. If patients lead… providers will follow.

Dr Peter Small built and ran the tuberculosis program for the Bill & Melinda Gates Foundation and conducted pioneering molecular epidemiologic research at Stanford University. He has long focused on the use of innovation to improve health care around the world. Dr Small founded the Global Health Institute at Stony Brook University and worked on the use of technology to improve health care delivery in remote Madagascar and Nepal.