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>> Welcome everyone. Today to our third annual Institute for Bioengineering and by a science. Distinguished lecture. We started this in two thousand and one our first big here was Dr Kenneth Shine who the time was president of the Institute of Medicine of the National Academy of Sciences. Ron we've got a place up front for you.

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Our second speaker last year was. Our Collins who is chairman and C.E.O. of Medtronic one of the largest medical device medical implant companies in the country and today it's a real pleasure to have so Richard Sikes who is director of Imperial College London for those of you who don't understand what a rector is the term are commonly used in the U.K. is vice chancellor.

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But here we would call the person president he basically. You know if you're a faculty member you would view him as the chief servant of the faculty. But he runs and runs the university and really the leadership from that person on top is critical as I hope you realise about Georgia Tech lot of what's happened here is become has been because of the leadership coming from President Cluff and our problems around Loucheux and in the deans.

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Now. So Richard Sikes he was born in York Shire I think raised there as well and. Did his first degree as undergraduate degree in London graduated with the first honors went on to do a doctorate in microbial biochemistry at Bristol University. And then began his what you might call professional career.

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Joining Glaxo in one nine hundred seventy two five years later moving to the US to Princeton New Jersey. To the US. Institute for Medical Research. He was in Princeton basically ten years. And then came back to collect so. And since being there has gone through a variety of positions and of course Glaxo has evolved in its own way.

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From Glaxo to Glaxo Wellcome to Glaxo Smith Kline. A major major pharmaceutical company his last two years there he was chairman of the board of Glaxo Smith Kline. But he also took on a few years ago the position of rector of Imperial College. And I know from my friends at Imperial College that he's been a very positive influence there.

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He has many honors to his credit. He's a fellow of a number of different professional societies and fellow of the Royal Society. He has a number of honorary degrees. And he was he had his knighthood in on the New Year's list in one hundred ninety four. He really brings sort of a unique perspective and that's why we're so privileged to have him as our distinguished lecturer this year.

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Because he's been a researcher. He's been a corporate leader. And he is now and I could Demick leader. And so it's a real pleasure for me to welcome you. Richard and to turn the podium over to you. We're all looking forward to your talk on harnessing new technologies to improve health.

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Let's welcome thank you. Thanks very much Bob And good morning ladies and gentleman. It's certainly a great pleasure to be gave the teeth lecture this year and I want to thank Bob for that because obviously he was the. Instigator. Got me involved and it's a great pleasure to have that opportunity.

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And during my talk today I want to share with you some of my ideas about how health management may change over the next few decades. And in particular I want to describe how new technological advances might change the look and feel of health care and then consider what barriers there might be to progress but first let's take a somewhat analytical view of health care.

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So what we see here are a six major themes that appear to be of particular importance in creating the drive for advances in medical capability. Prevail in medical needs technological possibilities demographic and social values expectations economic realities and the political and regulatory environment. And understanding these factors and how they come to play with each other is vital to understanding how the potential for scientific and medical advances can be fully realized.

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And although what I want to concentrate on today in my later a technological possibilities are also touch on some of these other areas because they are quite important. So first of all let's look then. Present and future medical needs as we might see them and although medical care is constantly improving.

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I believe that needs at least over the next two decades will remain very similar to those that we see today cancers degenerative diseases infectious diseases diseases due to change in dietary habits lifestyle like cetera. And as these figures demonstrate the common scourges afflicting todays society represent a talent show.

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Of immense scale and if we just think about Alzheimer's disease that's a pretty terrifying statistic when you think about it and neurodegenerative diseases generally. Asthma. And asked me if we just take the U.K. three million people a year in the U.K. affected by Asmer and that includes a lot of young children children today I'm becoming much more prone to Assman than they ever were in the past breast cancer still an enormous problem heart disease.

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Still the world's biggest killer. And of course obesity diabetes now becoming a real problem throughout the world not just in the Western world but certainly also in the developing world and we now believe the pieces to may well be a major risk factor underlying some of the most important causes them ability and death today there are clear links.

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Of course with obesity to type two diabetes to stroke and to heart attacks. And they're also apparently the cancer. Certainly the incidence of breast uterine and colon cancers are all elevated several fold in the obese population and they may well be links to other conditions to suggest degenerative joint diseases.

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And it's therefore pretty obvious. I believe that tackling obesity would have enormous and far reaching impacts on health in general and also the economic status of individuals and nations and various approaches often in combination will certainly be needed including alterations in lifestyle and selective drug therapy. However as in so many other aspects of health management a major education campaign will also be required far more effective than the ones that we offer today.

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The statistics The shown here on obesity and diabetes diabetes illustrate the so. Scope and depth of the problem worldwide something like three hundred million people are now clinically diagnosed. There's been a piece you know in the United States. It's a quite a high number but it's not very different in countries in Latin America or in Europe and the B. city underlined something life five thousand deaths but weak in the US a big number in the U.K. diabetes cost the health service hundred sixty five pounds every second.

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So these are statistics that really coming now to people to understand and bear on this problem and as we can see there are a major social economic health related issues associated with obesity diabetes in their Sekulow. And obviously these are not just cosmetic problems and I have to say that because I'm not sure that all doctors today yet see the real importance of dealing with these issues of overweight and obesity and I'm certain that those who have to pay for health care provision always rate these treatments of not worthy of reimbursement.

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And if this is a representatives of society's determination to tackle the problem then we've always They've got a hell of a lot to do in changing understanding opinions as well as developing new medical approaches to some of these issues. Now as the media are constantly alerting us infectious diseases continue to represent an enormous challenge to biomedical research and health care delivery.

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Still today one third of deaths worldwide are caused by microbial diseases bacterial diseases. TB We thought TB and disappeared from the face of the earth yet two billion people remain infected and it kills about two million people here many of those again young children. Viral Diseases an enormous problem influenza still a major killer H.I.V. of course major killer thirty six million people infected many many more of died.

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Hepatitis C. a big problem something that we wouldn't have known about ten years ago. So these are diseases that really are. Modern diseases if you like through through for all sorts of reasons parasitic diseases that we tend not to think about but still an enormous problem for mobility in the developing world two hundred million people are affected by She's to Semei asis and the cost malaria stills kills three million people a year.

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Most of those. Children under the age of five. So these are still significant diseases and then of course on top of all are. We've got pretty arms and not only do such diseases represent personal logistical burdens. But increasingly ethical dilemmas arise. And I just give you a couple of examples of those.

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We now have the capability to detect these abnormal prion proteins in surgical biopsies. But without any current top of treatment. What what do we do with the information if we know the those prion suppressant or if we believe that the increased cause billeted between countries is responsible for spreading diseases to countries where the disease was not previously.

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Present is it acceptable then to insist that certain people be screened before in the aggression permission is given a nurse the big debates that are going on in Europe at the present time. Of course society needs and expectations are also changing as a result of the aging population and an aging population is both medical and economic impacts.

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The prospects for major economies. Around twenty percent of the population will be over sixty five by twenty twenty must mean that health care services will need to look for new ways to help the infirm often less people intensive measures will be needed. For example use of technology associated with activities of daily living will enable more elderly often infirm people to live longer in their own homes and such technology of course could comprise of aids to help people move to manipulate but it will almost certainly involve a range of monitoring devices which allow for effective remote care such technological care could well prove to be more effective in some circumstances than medical intervention in terms of quality of life and certainly the cost of care.

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So I think then we can all agree that there are still enormous medical challenges and what I want to do this morning is to explore how new technologies will lead to new capabilities which in turn will raise new possibilities in medical care. It's not an exaggeration to say that science today is unrecognisable from that of one hundred years ago when transistors were unknown and the secrets of the basics of life and disease were a mystery.

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Now we can decode the genomes of organisms in a matter of days or at most a few weeks as was done. Of course with the SARS virus that we all heard about the microelectronic Revolution two has been amazing for example. It's now possible to integrate around a billion transistors on a single silicon chip one or two centimeters square and so even the most mundane of everyday goods today.

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Now has smart technology and bedded within it and the. Yes the pace of change seems even faster and here I've shown a few of the next generation of technological platforms which are already starting to revolutionize our ability to understand the basics of disease and at least do something about it in practical terms more often finding cures than power Asian.

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Taken together these technological advances will lead to a whole range of new ways of managing disease from diagnostics to cure. And going all the way through that diagnostic process of course one of the great attractions should be the prevention of disease. If we can understand the underlying mechanisms and do something about it before disease actually occurs then the prevention area is going to be so critically important both for the quality of life and also of course in terms of economic gain.

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Current drug therapy and surgical approaches will be supplied mentored or even replaced by new types of intervention to improve longevity and the quality of life and crucially we're starting to view an investment in health management as a prerequisite to sustained economic growth. And I believe that many of the step changes in our knowledge and capabilities to improve health care will result from the fusion of the basic sciences and technology is so it's critically important that we still teach mathematics in anatomy and physiology in chemistry or medicine but these of course will help us to develop new platforms such as bio engineering bioethics imaging tissue engineering which then will lead to give us new health care tools so that we can do robotic surgery so that we can do noninvasive diagnosis so that we can have preventative medicine and of course these in turn will lead to enhance.

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In improving the quality of life and creation of search process possibilities are going to thrive in environments which encourage multidisciplinary research. And these new technologies are inevitably going to cause somewhat of a perturbation in the provision of health care because they may not fit easily into existing models of payment or provision and there's also a potential that they will change the shape of the industry particularly as the current health care industry such as buyer pharmaceuticals may not be ideally placed present to capitalize on this type of multidisciplinary approach.

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So listed here they know my nine new capabilities which I believe will be particularly important in transforming health in the twenty first century. And although I don't pretend that the list is exhausted if I do believe that our Vance's in all these areas are already beginning to make an impact a more major benefits are likely to become widespread during the next two decades and as I deal with each one of these in turn.

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I hope you will see just how important it is this fusion of different engineering and scientific disciplines is becoming in defining health care solutions for the future. So let me start there with some exciting aspects of structural biology. And use in modern X. ray crystallography and M.R. techniques we can now begin to understand our biological molecules interact with each other.

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Receptor is with their lie Ganz enzymes with their substrates and from such knowledge we can start to build and design new drug molecules from the bottom up and hence improve the efficacy of drug design and discovery process. So here we go. And see a bit of the protein structure in the corkscrew the veil the white veil represents the active site in this case of an enzyme and there tucked in the active site is a molecule which is actually inhibiting in the enzyme because it's fifteen where the normal substrate would go into that active site and there.

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It's been called crystallized with the with the enzyme with the protein and we can see exactly how that structure fits into the active side and we at Imperial as many other places are now established a center for structural biology to exploit such techniques and technologies and thus understand the biological interactions better with a view to finding better therapeutic targets.

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And what I want to show now is just how we using sort of this information and target data to actually think about developing new types of drugs. And increasingly we're starting to link gene defects to potential drug targets and as an example a number of rare liquid malabsorption diseases have recently been identified and the gene.

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That's responsible for like a protein transport has recently been discovered a team of imperial Imperial College. And what known mutations in this gene cause a complete block of dietary absorption by interfering with the protein function you can actually see these mutations there in purple here on the protein and those mutations then stop the action of the enzyme and prevent action and whilst no clear therapeutic target for treatment of these rare diseases themselves emerges from this new knowledge what it does though the mutations give us a clue to how the enzyme binds its substrate and hence then suggest a strategy for creating a new brew.

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Lead of. Until obesity drugs because we can see then that if we can stop liquid absorption that obviously is going to help in that process so they would develop drugs for a much wider population and work in that area is already started and it's this is again an excellent example of the increasingly important process whereby a disease is genetically characterized a specific gene in its product to been identified and then a drug discovery strategy has been proposed.

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And this leads nicely then to the second topic on my list which is genetics and of course I can't cover this in any great detail but what I would like to do is just GIVE YOU WANT TO TWO examples of where genetics and associated tools will play a very important role in improving the diagnostic diagnosis and treatment of disease.

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The decoding of the genomes of the host that solves troublesome vectors such as mosquitoes a major invading organisms is now starting to shed real light on the molecular basis of disease and pathogenicity and I absolutely convinced that we are now in a new trajectory in Metson one which leads us to cure and prevention and not just palliation.

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And it won't be too long before we have ready access to chips with the rays of the complete set of human genes coding sequences for a relatively modern cost after metrics already have a gene chip with the entire genome of a person on the chip the prices of those things will come down quite significantly and then this of course could lead to different types of health care in which risks are predicted to manage proactively throughout someone's life and in fact and.

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Examples of those approaches are already starting to take place. And as an example let's consider how the definition of disease then may actually change. Increasingly diseases will be will be defined from a knowledge of a patient's underlying genes the gene a type as opposed to signs and symptoms which is the phenotype.

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And with the improvement of diagnostic capabilities the heterogeneity of common diseases such as diabetes are out Symes disease will become a Christian leader increasingly apparent today a clinical diagnosis about Simers is made on the basis of behavioral criteria that is on the basis of phenotypic information. However we already know that the number of linkages between gene mutations and apparent disease is there and if you just look at this slide you see the press and millions of mutations on chromosome one and twenty one.

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You've got mutations in other chromosomes in the genes on the chromosomes and each one of those of course leads to what we today define as out Simon's And therefore it seems very unlikely that a single drug will be appropriate therapy for all patients. Unless it's highly likely the recognition of disease heterogeneity at the genetic level will lead to the development of multiple therapeutic or preventative strategies.

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There's not going to be one strategy for dealing with those different situations. And to some extent this is already happening as we know that the efficacy of the reverse. Reversible coalesced arrays inhibitor Cognex is linked to a lack of the apple for our yield. And hence because of what we know from genetics twenty five percent of out Simas patients respond to Cognex and that's because we know that only twenty five.

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Saying carry the genes. So for many common and chronic diseases the situation may be even more complicated because we've got multiple contributing molecular variants of several interacting susceptibility genes and these will lead to multiple clinical outcomes over a very in time frames. And here is a simple analysis of type two diabetes which I'll use as an example of how the new knowledge will lead progressively to personalized medical solutions already a number of linkages to type two diabetes have been identified and the trick now is to relate these risk factors to treatment outcomes and hence to optimal treatment protocols.

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And in such circumstances diseases might be described in terms of responsiveness to intervention. That is X. responsive diabetes. The more linkages we find of course the more complex the task will become and hence I don't see a sudden emergence of quick fixes for poly genetic diseases simply on the basis of a greater insight into predisposition genes.

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However such knowledge will certainly help in defining lifestyle a medical regimes. The diabetes example leads me to a consideration of the concept commonly referred to as pharmacogenetics that is the use of genetic profiles to predict the patient's responses to met sins' pharmacogenetics is based on the belief that understanding human genetic variations will allow us to explain the differences in the effectiveness and side effects of mate scenes and hence fit medication more appropriately to individuals in other words personalized treatment so.

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If we can detect those changes if we can detect the single polymorphisms within the genome. Then we can identify which people are going to be much more susceptible to adverse events or. In a sense respond more efficacious slave to a drug and by adopting such approaches. It's already possible in some cases to identify certain populations with either end and harm static A-C. response or an increased incidence of adverse events and such knowledge then will help us to determine in target populations for drugs in some cases it may also determine of course whether a drug will or not be approved by regulators if overall efficacy or safety is poor and no simple targeting strategy can be determined the drug may be proved may be not provable.

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And pharmacogenetics approaches are likely to become routine in the relatively near future say over the next five or ten years. And this will lead to much more specific information being provided on how met since should be used that is what indication should they have what's the dosage that should be used the unwanted side effects general warnings can all be determined from understanding pharmacogenetics and general information of this kind will certainly become a standard part of all drug development programs in improving safety alone the gains will be significant.

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In the United States today adverse events to drugs are the six leading cause of death. The F.D.A. estimates that almost ten of one hundred thousand U.S. citizens die each year. From medical errors that is the wrong drug to the wrong patient and adverse events certainly represent a major cause for hospitalization.

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So if we can do away with a number of those factors then obviously that's going to be. Very beneficial. Of course pharmacogenetics approaches will also allow optimize ation of efficacy and here's a very good example of where genetic data as laid to say the sex sex will target in of the right drug to the right patient a sect in is you know is a treatment for a particular form of metastasize in breast cancer.

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And it shows pretty poor efficacy in the general population in fact the efficacy if you just going to the general population is about six percent. And in traditional terms in a second would never have been developed because the efficacy is far too lol. However the recognition that her two gene which is the human epidermal growth factor receptor linkage to these changed all that because it.

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Impatiens the sure strong expression of that gene then you get a much much better efficacy rate to her. Cept in and that rate shoots up dramatically. So knowing the patient to carry the her to gene which over expresses itself then those patients are going to benefit very significantly from Herceptin until diagnostic tests and are commercially available and hence the targeting of this drug is achievable.

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So I'd now like to turn to the third of my nominated breakthrough technologies and that is Mehta banal mix a relatively new concept and this is being pioneered by a team at Imperial College led by Professor Jeremy Nicholson. And in simple terms this approach examines how metabolic our metabolic metabolic plans change status of health so that new diagnostic a monitoring procedures may be defined.

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So the step sister involved here. First of all we need a biological sample so that might be blood or urine then that sample is is just sticking. And then I'm on machines so you get an enema spectrum that data is then transformed to use in pattern recognition systems algorithms and then from that we can predict where the medical intervention should take place.

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So this is a pretty exciting technology and here. What I want to show you is some metal been amik profile in that can be used to diagnose important diseases in this case to bone diseases which are associated with an aging population. Osteoarthritis and osteoporosis. And what we've done here of course again is taken some some blood stick it into the machine mathematical transformation of that spectral data is then up ten from those Venus blood samples and then being calm player with clinical data to predict whether those patients would would have the disease or not.

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So in the first example which is osteoporosis the red triangles are just controls those people who are normal they do not suffer from osteoarthritis in the blue circles if that's what they are blue circles are people who have been diagnosed clinically to have osteoarthritis. And then along come the patients that are blind.

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And those patients are not clinically diagnosed now sample of Venus bloods taken from those patients injected into the N.M.R. machine there metabolic problem at a bullet. Profile in carried out and they're the black triangles. So you see black triangles appear so they don't really have the disease. You see black triangles down here and they do and you can see what then when they go on to be clinically diagnosed the class prediction is ninety percent ninety nine percent confidence limits.

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And the same with osteo proces we've got the same situation down here. The red triangles of the controls the purple squares are people. Been clinically diagnosed to have osteoporosis the black triangles again a people have come in. Blind. They had been tested through might have been all mix and now there's a ninety nine percent plus prediction of the ninety nine percent confidence limits.

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So in a case of osteoarthritis. Today there are actually been no eye stablished biomarkers for disease. Until the introduction of this technology. So it appears then that we have a simple tool available to monitor disease progress in the in the case of osteoporosis which affects millions of people worldwide and is increasingly more common normally requires complex X. ray procedures to assess the magnitude of the problem.

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This is costly and obviously not suitable for large scale population screening this metter but normie test is potentially much faster and a cheaper alternative allowing more people to be screened early. So the pro progress can be monitored and equally important of course the new biomarkers generated by this procedure are already given new information particularly on mechanisms underline the disease and may eventually lead to new drug targets.

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So this is just one example of where Mehta Bonneau mix now is having a real impact but there are many others and you can just imagine that because in health and disease the metabolic pattern. He is going to change quite significantly. The next to my chosen drivers of medical advances is vaccination.

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And whilst the potential for vaccination as a way of preventing disease has roots in the eighteenth and nineteenth centuries recent advances in vaccine technology lead. I believe to exciting new opportunities and this slide shows some of these advances. First of all genomics and proteomics help us identify new.

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Potential targets D.N.A. vaccines are now becoming fascinating ways of stimulating the immune system directly by just just plain D.N.A. on contaminated with anything else. Understanding the immune system of course critically important the way that it responds to these antigens new types of Agilent to get better and response.

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But also new delivery technologies. And the conventional concept of vaccination of course is the needle and the syringe that we saw up there but at the bottom here we see a gene gun on the gene gun really takes gold particles delivered we coated with D.N.A. and then delivered non-invasively into the target tissue.

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And it's becoming clearer that D.N.A. Faxon's today will be very useful in a number of important situations. Once more is understood about the technology and the immunization process and the way that the immune system reacts to the naked D.N.A.. In fact advances in understanding of the process involved in immunity and rejection will do much to help us develop a new range of prophylactic and therapeutic interventions.

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I showed you earlier our malaria particular in young children still remains a major public health problem. At Imperial now we have a major research program seeking new ways to compound the disease at a time when the causative agent which is plasmodium has become resistant to major drugs and the vector the most Quito becoming resistant to most pesticides.

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And through detail knowledge of the lifecycle of plasmodium in both the host and the vector new approaches to combating the disease have been pursued. And already there is good progress on. A number of these fronts novel methods have been found to disrupt the transmission of the parasite using vaccines drugs and genetic manipulation of the vector itself to allow it to amount to an immune response against the parasite.

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So the vector kills the parasite before it can transfer the parasite to the host. So lots of opportunities now using modern molecular technologies to get a malaria. Moving on to buy only. Which is my fifth category of breakthrough technologies this example shows how our Vance's in our ability to tackle disease will certainly come from interfaces between Metson and engineering the design of the miniaturized electronic cochlear involves the expertise of a group at Imperial and a professor Chris to Mizzou in the bio engineering department and of course Bob has been very closely involved with this for many many years.

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And this particular device now is progressing into humans in the clinic. And all of the team a look at there already. The team are looking further at the creation of artificial retinal implants using this technology to help people with macular degeneration obviously to to give them back some useful site.

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And search technologies based on analog micro power not digital micro part of that helps and they're going to make possible the repair or restoration of function to a variety of organs which in the past would have been deemed irrepairable. In actual fact we know that a number of buy only can buy a tell them treat devices already exists it is the implantable heart pacemakers and devices to a blood flow through diseased organs.

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However over the next few decades such by our Nick devices are likely to become commonplace much smaller. Unless demanding of maintenance. And you can see here. Some of the things the are actually going on and are Vance's in creating effective Bonnett devices will be essential if we're to provide quality of life and acceptable measures of independence for an aging population of patients who survive disease having creasing levels of disability.

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And I want to move on to my six category of new technology a very different and very topical issue among which illustrates how new technologies demand a change in attitudes and legislation stem cell research offers the hope of huge benefits in the treatment of serious illnesses by replacement of diseased or damaged tissues and empire in pioneering major advances like they sell over there is frequently nervousness disbelief or even open hostility.

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And all too often. This leads to over restrictive regulation which prevents progress. And I recognize that the situation here in the US is quite restrictive. But a number of governments including the U.K. government have taken a brave step I believe in creating a clear regulatory framework where such work can now progress ethically.

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And I'm therefore confident that important progress in this field will be made. And the stem cell culture technologies will lead to therapeutic solutions for a number of devastating degenerative diseases. Here are shown some basic processes that will be used for engineering tissue transplants first stem cells will be directed to differentiate into a stable and stage cell type then they will be encouraged to grow on a suitable biologically calm.

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Possible scuffled where they secrete proteins needed to form an extra cellular matrix and hence form cohesive tissues the engineer tissue would then be available for transplantation of which the scaffold would then be reabsorbed while the tissue grows in situ and work of this nature is being undertaken by biologists physicians and engineers working together in tissue engineering centers both here Georgia Tech under to imperial at Imperial we have deigned Julia Polak and Laurie hench the Bob knows intimately and they've been collaborating for many many years in these areas but these are areas now that are starting to take off things are starting to develop in fact a number of recent publications just show how rapidly the potential benefits of cell therapy and tissue engineering are approaching.

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And you can see some some recent announcements here. Also other announcements include production by American scientists a viable kidney and heart issues from both of our fetal bovine fetal cells and heart tissue from rats stem cells and already the potential for Hughes in human stem cells to repair disease hearts has been explored.

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So a lot of a lot of things going on here quite exciting. My seventh nomination of revolutionizing technologies is imaging an M.R.I. image in will undoubtedly grow in its importance as a precise noninvasive tool for diagnostic and treatment of disease and it's quite appropriate I believe that. Now this technology has been recognized with Nobel Prizes to pull a lot of current Peter months field.

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And it's appropriate that it should be the people who actually develop the science a lot of allow the technology to develop. But. This very very critically important tool. First of all file compression software already exists to access all the scene from ation from a distant disparate sources say that in the bottom right there.

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The C. will soon be possible to match patients almost instantaneously with medical records anywhere in the world. If you have access to the system. Virtual organs that we see here on the right. Develop from three D. dimensional reconstruction of images also allow surgeons to practice techniques before carrying out the real thing and the increasing detail that's been achieved by this technology is going to be very very important.

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Also in drug development and in of the treatments and you can do that today using this technology non-invasively follow coronary artery Payton say for example and to illustrate these these new capabilities. Here are two video clips of how modern imaging techniques can be used to visualize vul function and blood flow in the heart and again it was the work of Peter man's field that allowed always stuff to actually happen.

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So what we see here are on the right first of all is blood flow in the right ventricle. And then we can see the heart in situ. Again this is using non invasive technology. Quite remarkable technology the definition of that today. Another major step forward in using imaging The shown here.

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The ability to carry out. Whilst tracking the exact position of the tip of the end a scope to with point one zero point two of the millimeter. So in this case the end a scope is actually explore in the epidural space in the spinal column. So we going up and down the spinal column on the Left dot on the image shows you where the tip of the end a skull plays such innovations.

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They're already been used in medical practice and will allow for major advances in precision microsurgery. A concept that will become reality in much of future health care delivery will be that of sense in a monitoring and hence I picked this is number eight on my list of important new technologies and here's a glimpse of our health care status might be moderate monitored remotely in the near future.

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And this life shirt is embedded in it. Sensors that monitor over thirty vital signs of cardio pulmonary function which are collected by a personal digital assistant and then these signals are sent to at intervals by an online service straight into a central repository and then you can get feedback from them.

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This particular device been developed by an American company called Viva metrics and now has F.D.A. approval for use this this device is actually on the market. My final category of promising new technologies illustrates how our Vance's in both biotechnology and bioengineering will revolutionize the practice of medicine on the left is a view of a virtual operating theatre.

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We have one of these at our premises at Chelsea and Westminster campus that's a big hospital in London in which operators can simulate many events to test student capabilities such as massive hemorrhage and cardiac arrest. Techniques like this of course allow modeling of responses to various interventions. But the picture on the right is the real thing that's the surgery.

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This is taken as marries another of our spittle campuses but here. Robots are actually controlling the instruments with precision greater than that can be achievable by the unaided human hand and the result of the capability to carry out minimally. Invasive surgery without subjecting the patient to unnecessary surgical damage really comes from this kind of technology.

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Here for example is a patient following minimal invasive crown a artery graft in done by a Professor Ira Darzi the merriest campus at the Imperial because he's the guy is really pioneering these approaches with a robot called the Vinci. And of course that leads to all sorts of possibilities telling Mattson surgery taking place where the surgeon is not actually in the location of the patient.

[00:46:38]
All right so the thing is is now starting to become commonplace. And what I'd really like to do is is further develop this concept to medical robotics by describing our mechanical engineering team a team Piro has pioneered a suite of software and hardware tools for use in orthopedic surgery.

[00:46:58]
The interventions of the team led by Professor Brian Davis a become the core assets of a spin out company called Acra bot which last year when the J. and J. best surgical Innovation Award. And conventional orthopedic surgery and joint replacement surgery in particular has changed little since it was developed in the one nine hundred sixty S. You know what they say about an orthopedic surgeon strong as an ox and half as intelligent and still applies today.

[00:47:29]
But traditional traditional author P.D. tools range from the hammer and chisel to the power drill and soul and these are used to replace natural human joints with manufactured implants and prostheses and conventional techniques using these tools obviously require a lot of skill of the surgeon a lot of training and involved procedures that are not only stressful to the patient but also stressful to the surgeon failure rates in these joint.

[00:48:00]
Replacement procedures can be as high as ten percent for talk will knee and hip replacements done and a significant number of these failures are actually put down to inaccuracy is jury in the fifteen of the implant. So Acrobat researches of actually develop the concept of active constraint robotics or a C.T. which prevents surgical error by actively guiding the surgeon through the operation and with this technology.

[00:48:31]
The surgeon really remains in control throughout. So you've got propriety planning software allows the surgeon to provide the form the virtual surgery ahead of time. And then during the surgery the robot provides the precise geometric accuracy and also increases safety by means of a predefined three D. motion constraint which prevents.

[00:48:58]
The cut in anywhere outside the defined region. So here are ideas generated by mechanical engineers have through intervention with physics computing and surgery lead to a new generation of capability precision in orthopedic surgery. And the story is far from finished because already a team and now developing an exciting new capability which is single condyle replacement surgery because in many cases it's only one side of the knee joint was severely damaged and it would be highly attractive if you could just replace that side of the knee joint using minimally invasive surgery techniques which we can see here and clinical trials a currently underway and initial results look at extremely promising you can see here the picture on the right is a C.T. scan of the knee this received a single condyle prostheses So these things are now starting to be done.

[00:49:58]
So. There's no question on the whole these technologies that I've talked about and described have got tremendous potential for the future and I'm just now like to touch on the few of the constraints the could hold back some of these issues and so these are these are issues that really have to do with expectations from all this technology expectations in health care and the willingness to pay for all the stuff that's going to be available and I'd like to start by considering the expectations of people.

[00:50:34]
Patients are now becoming active involve consumers of health care a trend which most doctors will not actually welcome. Because patient groups are now becoming more common more active and the Internet of course is transforming the amount of information can be assessed directly by patients already thousands of Internet sites carry health information and we must anticipate that more house souls in the developed world will sooner or later have access to this information in the U.K. about fifty percent of households today have internet access and I'm sure the percentage is even greater in the U.S..

[00:51:18]
But the question is what people have access to what is that information can we assume that the information is available will be fairly balanced. Will it be true. Will it be communicated at a level which aids understanding. And obviously there's tons of will concern about the way in which our Vance's in science and medicine.

[00:51:40]
Are represented to the public the communication issues a major. And beyond the scope of today's talk but the resolution of that is going to play a vital role in next ensuring that the expectations of the public a well founded and realistic because if we get that wrong then we could all be.

[00:52:00]
Fire and things could go badly wrong. A characteristic of today's society of course is the growing belief that everything must be one hundred percent safe and that if it is not some one has been deceived for or negligence. However I doubt very much. When the Most people actually have any real concept of the relative risks that they face in the pursuit of normal everyday activities and I've shown here some research for voluntary activities in order to illustrate the point.

[00:52:32]
And if we wish to win patients confidence in new technologies. I feel we really have to talk much more about the risks and probabilities and less about black and white outcomes in more general terms we must look how to educate children and adults about health management. So that expectations and demands evolve in a well elaborated context.

[00:52:56]
Arneson are impressive impressive resources into public education programmes will need a concerted effort. From many parties we scientists and clinicians must always seek opportunities to take a proactive stance. Whenever we can. Turning now to economic issues the economic value of the of an increase in life expectancy is remarkable.

[00:53:22]
According to recent calculations in the United States. Eliminating deaths from heart disease would generate economic value of forty eight trillion dollars a year curing cancer would be worth forty seven trillion dollars a year but more realistically just by reducing the death rate from either of these courses by twenty percent would actually end up saving the US ten trillion dollars a year which is more than a year's G.D.P. so.

[00:53:53]
R. and D. might be expensive but it's less expensive the sort of activity. So I think that. Investment is critically important that we keep putting money into research and development to reduce this in efficient issue. Here's another compelling example of economic benefits new technology can bring and you can see here that modern drug therapies for schizophrenia have enabled many patients to actually live outside the hospital and they do that to greatly reduce cost.

[00:54:26]
And that can be applied. Of course to many other situations could be applied to buying it. Devices or new surgical techniques for the diseases and of course the important thing is to look at health care holistically. And then you can start to save a lot of money and we may consider the you know innovative approaches to medical care expensive but at the end of the day in the long run.

[00:54:50]
They're often going to be cheaper. So in summing up than I am I must turn to the consideration of what might facilitate offer straight the unlocking of the enormous potential promised by new scientific technological innovations. And there's no doubt in my mind that these scientific advances in the pipeline today will greatly increase our ability to detect predict prevent and treat diseases in the future.

[00:55:22]
And that these are Vance's will emanate from a wide range of new capabilities that we've talked about other technologies will also increase enhance the quality of life for those not considered in conventional terms. While some advances will save money overall and must be welcomed by health care providers.

[00:55:43]
Demand will certainly increase as we provide much more personalized care. So without doubt new social economic and ethical issues will abound in this new paradigm. In fact a number are already with us. And I've tried to illustrate here. Five of the major dilemma which we will have to address if we're going to be really successful in unlocking the potential of new technologies.

[00:56:12]
Individuals to become dissing gauge from science and medicine and that's true. I guess in many Western countries for all sorts of reasons we're going to bring that trust back into into the arena personalized medical care is a real possibility but of course health care systems are driving in a different direction that they delivering health care for the greater good.

[00:56:34]
Not for the individual. And of course value means different things to different people. I think all the regular train violence are going to be critically important under course this issue of demanding more and more he's going to be available. And can supply meet demand and these all these issues only serve to emphasise the thesis that human inventiveness is not going to be the major barrier to improving health.

[00:57:01]
It's all these other issues that come into play. I've got no perfect answers to these dilemmas. But I do see closer alignment of expectations of different stakeholders. There is key to ensuring the valuable new capabilities realize their true potential. And this means alignments between industry between health care professionals regulators governments and the individual.

[00:57:27]
And that's a tall order because of course all those people have different motives and priorities and sometime they bound to differ in one time or another. However in many healthcare systems a strategic shift of focus is already discernible one in which there is a recognition that the quality of care is more important than the cost of containment and hence the inputs to the system must result in measurably better outcomes.

[00:57:57]
So it's now vital. All stakeholders strive to align around the creation of mutually acceptable outputs and the apparent preoccupation with metrics actually targets. What is important to individuals or one way or another pay for health care provision. So in summary. I'm certain that the new technologies will lead to new capabilities and health will benefit as a result.

[00:58:27]
However I also believe that current health care provision paradigms will need to change if access to these new developments is to be guaranteed Social Attitudes to a number of potential changes will be part will be of paramount importance and I have no doubt that patients or potential beneficiaries will demand a greater say of how their health care is managed in the future.

[00:58:52]
And if we can address the economic and social or political issues. I have described I believe the major changes in medical care will emerge and provide options more tailored to individual needs and they do today. However to facilitate that transition. I also believe a more satisfactory level of public debate is required.

[00:59:15]
And I think that we have to have all parties involved in that academia industry government. If we're going to make progress. So what I will do now is leave you with my own personal view of the scientific and medical advances which are brought revolutions in the past two centuries and those which I believe will bring revolutions in this present century.

[00:59:39]
And from the nine new technologies I mentioned earlier and the outcomes I postulated I've chosen those which I think will be seen as the major breakthroughs. I'm sure there'll be many others but I am absolutely convinced that these things will happen. They will are very significant. To the quality and quantity of life.

[01:00:03]
Thank you. Thank you thank you Richard. That was a great the you very much appreciate your being here and I think Will. Take a little time for four questions or comments from the audience. Yes. Would you repeat the question I think the question is about we know what we believe that companies pharmaceutical companies by pharmaceutical companies are successful today because they produce the inverted commas the blockbuster which treats everybody in Cuba is nobody makes people feel better.

[01:00:59]
What once we start to develop drugs that is targeted to individuals per se using pharmacogenetics an example and disease redefinition So the tassel is not one disease but five diseases then will the pharmaceutical companies make money. My belief is that yes they will because I think they are providing a better service at the end of the day see Gone are the days when when salesmen used to knock down doctors doors and say prescribe this at all costs.

[01:01:32]
If it doesn't happen well it might but he shouldn't happen anymore and I think once people can take drugs knowing that they're not going to have an adverse event that they will benefit from it the way that people take antibiotics today. You know you take an antibody normal circumstances you kill the invader.

[01:01:49]
And you better you cure all of them. Now most disease not like that because it's not an invader it's some genetic mother formation that's taken place. So therefore you're going to deal with that one. She deal with it the way you deal with infectious diseases people's attitudes towards my simple change so.

[01:02:05]
I believe that yes you'll be developing specific drugs for specific targeted situations but their work back to their life less side effects will be more acceptable and the cost of the developing them will not be the cost of developing a major drug today simply because they told me today when you when you do clinical trials today.

[01:02:25]
You're very fortunate to get fifty or sixty percent response rate very very rare so because you don't want population to test the drug. If you knew which population to test the drug to make you a lot easier. What Chiba So overall I think it'll be OK. Yes really.

[01:02:44]
I would just take the microphone. Thank you so that you guys are so ridiculous that you've got your people. It's not. That's why I made the comment I didn't say anything about it. I need to correct a minute heart of Mark's right Michael. That we certainly aren't ready yet because as we've called breakthroughs love Miley.

[01:03:36]
Years ago because of problem lies with your United States government yet most everywhere else in the world except how can we prevent lawyers from for. I don't have an answer. I think it's an enormous problem and I try to bring some of that out because as I say I think we'll go on creating things will go on making things better and better breaking the boundaries but below was be some mechanism the is just keeping that at bay.

[01:04:19]
Whatever it is but I think the need to just say society that you have in the United States is now counter to good health care. Unfortunately some of that is spilling over into the U.K. almost inevitable. Nothing like it is in the United States but I think that's a big issue that has to be dealt with because nothing is risk free nothing at all and they started to the everything has to be black and white and if not somebody is responsible.

[01:04:49]
I think has to be dealt with. So I don't have an answer for you but I think it's a big problem. Comparing Europe and the United States. I used to think that it was easier to get new technology. Approved and to patients in Europe than in the U.S. but I have the feeling that some of the actions being taken by the European Union McMillian factor level the playing field.

[01:05:15]
You have any comment on that. Yeah I mean certainly they used to be a time when countries could did their own thing and they did the approvals and they got everything sorted out. But the more more European legislation coming in now into drug clinical trials is the latest one that's going to hit the business in two thousand and four and this will slow down the whole development of drugs in the European Union.

[01:05:45]
So there's a lot of angst about optically in the place like the U.K. which is renowned for getting drugs through the system quickly get them on to the market they don't pay for them but they get on with the market. They've always been very good but this legislation is now up in a big.

[01:06:00]
The impact and I think there's going to be a serious response to that from from from a number of countries but the clinical trials initiative is actually very detrimental to drug research and I think it was a question in the back there. And then we'll go to you Susan improvement like health it.

[01:06:23]
You heard healthy lifestyles continues at least in the United States do you envision any future roles individual responsibility sharing here. Yeah well I think. I think individuals do bear that responsibility to some extent in the United States still in most of Europe health care is free. The point of entry and there's little unless you want to go for private medicine which is still quite small in the United States about eight percent still eight percent of people have private coverage and that's usually through employment but health care is free.

[01:07:11]
That is a. That is a significant issue because then people want everything they can have everything so out of government's control what they control with waiting lists. So the only ways of a propagate keep up the structure get in there although it's free. You can access it. And that's becoming an enormous problem so again I think you're going to see a big change where patients are going to be asked to contribute to their health care one so that they can understand the real costs of the health care provision today in the U.K. G.P.'s have have about less than a minute or two minutes with each patient that goes to see them.

[01:07:48]
So you have people who really need a G.P. eighty percent of them to shouldn't be there in the first place but it's all free. So why not. And you don't have to go to work if you go to the G.P. so you can sit there for three. Hours do nothing and go back to work afterwards.

[01:08:02]
So if you paid ten pounds for example just to visit your G.P. you probably drop the number significant plate and make these people much more effective in dealing with their patients. So the the what you need isn't the toxicity to sort this lot out the problem in a democracy.

[01:08:17]
Nobody does do anything. Other wise enough people complain but something's got to be done. So is because it's this is a power question that you're at is the this is the way of the future but I was surprised to see just those that achieve the greatest medical systems to achieve that because many people are in favor of the greater good.

[01:08:50]
Your ethical position. What my point. There was the most health care systems are a developed to for the greater good. Not for individualized health care but of course we're going in that direction we're moving in the direction of enduring individualized health care of course and I don't think the two things are incompatible obviously research and development and everything that goes on will eventually be for the greater good.

[01:09:17]
Whether you do it for individualized health care initially or you do it for populations. But today because we treat everybody the same so in this room. If you said well I've got hypertension you get a similar sort of drug. Whereas if you looked at the genetics of your hypertension that drug that you were given may only work in forty percent of year the next drug may work in the other twenty percent and so on.

[01:09:42]
So that's what I'm talking about. So if you say the greater good is to treat forty percent of me and the rest of you suffer doesn't seem good to me. Whereas if you can all be treated individual in the sense that you all fit in the same kind of of hypertension because you've all got the the same genetic modification.

[01:10:00]
And surely the benefit is for the greater good. But you've been benefited as individuals because you've been identified as belonging to this group and not modernist group there really is only defined by phenotype and not by genes. I think. I think we probably need to bring this formal lecture to to a close couple things before we do that.

[01:10:23]
Number one I certainly thank you again Richard. There is a very nice honorarium that goes with this lecture. This and below is symbolic of that I say symbolic because it's an empty envelope Why is it an empty envelope. Well you know of said Richard is used to dealing with faculty and faculty are used to giving empty envelopes to the administration but in fact the easiest way to handle this for someone coming from the U.K. is a bank transfer so it is symbolic of our Thanks for our wonderful lecture and for your being here and let's close with a round of applause and I welcome all of you to there was something that you fifteen.