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What future for medicine?

What does it mean to be healthy and to age well? Are health and ageing – usually associated with the burden of chronic disease, disability and dependency – compatible at all? To introduce these questions, let me take you back to a workshop on «personalised health» that I attended a few years ago. The workshop brought together various stakeholders from the world of science, medicine and public health. After the usual round of presentations, the discussion suddenly became very tense. On one side was a promoter of genomics who defended the need to build infrastructure enabling the collection and analysis of multiple sources of data. This scientist was convinced that advances in sequencing techniques and big data analysis would advance medicine. On the other side, there was a dismayed public health representative who reminded the audience of the challenges that a growing ageing population poses to the healthcare system. The physician painted an alarming picture: a healthcare system short of infrastructure, beds and nurses in the face of growing co-morbidities and health needs; the ageing population as a ticking bomb that genomics could do nothing to defuse. At stake: two different visions of the future of health, technology and medicine.

The promise of the datafication of health

In Switzerland, the umbrella term «personalised health» refers to initiatives that aim to use multiple sources of data – clinical, -omics, self-tracked and others – not only to improve and better target clinical interventions and treatment at the individual level, but also to improve prevention and public health as a whole.¹ These initiatives are based on advances in molecular biology, sequencing techniques and information sciences. Datafication and genomisation promise to improve health through a better understanding of its genetic and non-genetic determinants across the life course, and the identification of new biomarkers that should enable a better targeting of health and medical interventions. The emphasis on environmental health determinants gives greater weight to the social, ecological, economic and political forces that influence health and promote a more holistic understanding of health rather than a purely biological one. In other words, these personalised health initiatives promise to reconcile biomedicine with public health, the branch of medicine that focuses on keeping populations healthy rather than curing disease. However, as the discussion during the workshop shows, the extent to which a technoscientific and biomedical approach to health is compatible with public health goals remains controversial.

Technoscientific and/or humanistic holism?

In the social sciences «holistic medicalisation» refers to a new medical regime, in which «each person’s whole dynamic life process is defined in biomedical, technoscientific terms as controllable and underlain a regime of control in terms of monitoring, quantification, prediction, risk profiling, early diagnosis, therapy, prevention and optimization that is all-encompassing».² To illustrate and reflect on its implications for ageing, let us turn to an international network of clinics, one of which is located in Zurich. «Your health is your most valuable asset», «invest in yourself», says its website. Promising to «prolong your life», empowering messages invite potential clients to take control of their health and achieve their goals in an efficient way. For up to 350 Swiss francs a month, the company offers blood and biometric analyses, the assessment of 50 biomarkers, self-tracking apps and personalised health and medical coaching on sleep, stress, diet, physical activity, tobacco and alcohol consumption.

These services promise, in a sense, to reconcile the best of two understandings of «personalisation», the humanistic and the technoscientific. They offer evidence-based prevention through technological innovation and the latest scientific understanding of ageing, as well as personalised coaching. But they also represent an economic view of health, in which health is seen as an asset that, if invested in correctly and early enough, will pay dividends in the form of long-term good health. By focusing on prevention, these developments contribute in some ways to the de-medicalisation of ageing by shifting the focus from illness to health. However, they also transform age into a category of risk, blurring the boundaries between health and disease, normal and pathological, and extending the logic of biomedicalisation³ to health and lifespan. They also transform health into an individual good, a kind of personal capital, subject to the same neoliberal logics that govern the market.

Ultimately, these developments allude to the promise that ageing can be slowed down or even reversed by consuming the «right» products and drugs, and by adopting the «right» lifestyle. They turn the process of biological ageing into a site of medical, pharmaceutical and individual intervention accessible only to the wealthy. They thus contribute to the individualisation of the moral responsibility for healthy ageing, reinforcing consumer logics and social inequalities in health.⁴

Shadowing alternative narratives of positive ageing 

At the centre of these processes is the category of self-optimisation.⁵ The optimal state of health is placed by specialists between the ages of 20 and 30, transforming this decade into a normative ideal to be preserved.⁶ Youth and health thus become new measures of success at the expense of alternative narratives of positive ageing. These narratives matter. For example, the anthropologist Margaret Lock has shown how, in a different context, where a positive view of ageing prevails, the embodied experience of menopause is different and not associated with the symptoms that are commonly used to characterise menopause medically.⁷ This means that the predominant social value of ageing in a given context directly affects the embodied experience of this process. The common understanding of health, conveyed in the personalised health approach to ageing, and in society more generally, is deeply individualistic and ageist. Somehow good health is the opposite of old age, and the process of ageing must be fought by all means. These means are unevenly distributed and their effects accumulate over the life course in a «recursive cascade».⁸ Therefore, the social and economic values of health and ageing matter. Not only do they affect bodies biologically, they are also embedded in infrastructures of care as well as infrastructures of data, challenging our collective capacity to care for vulnerable lives.