Dr. Marco Bevolo, PhD, Professor, Design Futures at World University of Design

How can the cultural values of our youth create a better healthcare system? Dr. Marco Bevolo, a writer, futurist, consultant and professor of Design Futures at World University of Design, explores digital behaviors and wellness beliefs of younger generations to map out a more positive healthcare future. Driven by mindfulness, he predicts an evolution to a holistic, sustainable, value-based system focused on an individual’s health outcomes. 

Dr. Marco Bevolo, PhD, Member of the Board Studies and Adjunct Professor, Design Futures, at World University of Design, is currently an international consultant in Foresight, Futures, and Strategic Design. He is a Philips Design Alumni, 1999-2009. He is Advisory Board Member and advisor to the President of ISISUF, Milan, the art foundation programming FuturDome, Milan, and the only authorized archive of the works of Carlo Belolli, Mary Viera, and Ada Ardessi. In 1999-2009, he was a Director at Philips Design headquarters in the Netherlands.

He led programs in cultural trends, in brand design, and in advanced business development. He directed foresight and strategic design projects for Philips Medical Systems, Philips Semiconductors (now NXP and Nexperia), and joint ventures with SHL Telemedicine, AEG Licht, and more.

As independent consultant, he contributed to the success of selected customers in Europe and Asia, including FIAT Chrysler Automobiles (now Stellantis); Chamber of Commerce of Turin, Italy; Municipality of Eindhoven, The Netherlands; Lighting Design Collective, Helsinki / Madrid; 515/BBB, Turin / Berlin, and more. In this extracurricular capacity, in the lustrum 2010-2016 he has been the Principal Research Urban Futures for Philips Lighting, now Signify, in EMEA and Poland. He has contributed to seminars and events with the Master in Service Design, School of Design, Politecnico di Milano, Italy; Emerson College, Boston; the UNAM Post- graduate School of Architecture, Mexico City; Domus Academy, Milan; IED, Milan; and more. He has been a 2019 Visiting Scholar at Vancouver Island University, Canada. He had his research published in: Journal of Consumer Marketing; Research in Hospitality Management; Journal of Tourism Futures; World Futures Review; Place Branding and Public Diplomacy, and more. He is the recipient of an Emerald Literati Award and of two ESOMAR Best Conference Paper. He is a Researcher and Lecturer at a leading University of Applied Sciences, The Netherlands. He earned his PhD on the role of design in generating urban futures at the Graduate School, Faculty of Behavioral and Social Sciences, Tilburg University. He lives and works in Eindhoven, The Netherlands, and in Turin, Italy.

Show Notes

• Dr. Marco Bevolo shares his design and education background. [04:25]

• An evolution of health care from a sick care focus into a wellness-based approach. [07:33] 

• How can mindfulness create a different approach to health care technology? [10:58]

• What type of healthcare system can deliver individual happiness and social stability? [14:31]

• In what ways can we rethink systems and redefine the meaning of health care and wellbeing in the future? [19:53]

• How do the younger generations approach health care? [25:52]

• Redesigning healthcare through the lens of sustainability. [28:28]

• An optimistic future in which a design choice can create a positive impact. [30:22]

Transcript

Bisi Williams  0:00  

Hi. I'm Bisi Williams, you're listening to Health2049.

Marco Bevolo  0:07  

I see more the human factor in terms of social cultural values, in terms of evolution of beliefs and the evolution of mindsets. So, for example, I see that it's becoming more and more common for millennials to bring mindfulness into the picture. I can think that with mindfulness, a different approach, a more holistic approach, a more wellness-based approach will be injected into the definition of what healthcare is just as an example, and that at that point, all the technology that you have available, will be geared towards a different purpose towards a different set of expectations.

Bisi Williams  1:28  

The next 30 years will be the first time in history where senior citizens make up a significant percentage of the human population in the West. This is a fantastic success story due to an unprecedented human ingenuity and the advancement of science. On the other hand, these changes will have a profound effect on our cities and the lives of the people who live in them over the next 30 years. The need to rethink care not just for the elderly, but for the young and all of life too, will have a profound effect for health and wellness for all societies. There'll be a point in all of our lives where we will be vulnerable. The degree to which society looks after its most helpless citizens reflects its values. How will we design our new normal? How will we define health? How will health systems work? We'll get answers to some of these questions and more from my guest, Dr. Marco Bevolo. 

Marco is a writer and futurist. He earned his PhD on the role of Design and Generating Urban Futures at the Graduate School faculty at Behavioral and Social Sciences at Tilburg University. He's currently a researcher and lecturer in international leisure management at NHTV Breda University of Applied Sciences. He is the founder of Marco Bevolo consulting working for selected customers in Europe, Asia, and including Philips Lighting Design collective. He's also an adjunct professor of Design Futures at the World University of Design. Hi, I'm Bisi Williams. And it is my pleasure to welcome Dr. Marco Bevolo to our show Health2049. Marco, welcome.

Marco Bevolo  3:54  

Thank you, Bisi and I'm really delighted to be here and to share this time with you to look forward to the next couple to three decades from the point of view of health care, wellbeing and especially design. 

Bisi Williams  4:15  

I'm so excited to begin this conversation, you have a very interesting background. Can you tell us how you came to be a designer and a futurist?

Marco Bevolo  4:25  

Well, it's a very interesting question that I get a lot. First of all, I must confess that I'm not a real designer. I'm more a sociologist, social scientists working about the future trying to anticipate, to inspire the co-creation of preferable futures with design research methodologies. When my dear mother saw my professional path, unraveling and rolling, she commented because she has been in the same job for 50 years, even longer. She commented, well, it looks like you chose the path of 100 jobs and 1,000 miseries. So she was really not approving of my relative job hopping, which is very normal to current generations. But it was not so common in Italy when I started working. I come from the creative industry in Italy, where I worked in automotive design in advertising, in publishing and where I actually had the opportunity to share with you the experience in Milan at Flash Art International in the 1990s. Then I've been for 10 years with Philips design, with the strategic design department, created by Eric Quint, who has been Chief Design Officer of 3M. And he recently published a book about design leadership under the leadership of Stephen Marzano in the 2000s. And then I build a portfolio of academic commitments as you described. I really love teaching, I really love students, in terms of intellectual mentoring of pastoral education, I'm very passionate about anything that has to do with education, but I also do business consulting, and I try as much as possible to keep myself in the fine arts and related words with commitments, in terms of advisory board or other sorts of service to cultural foundations and institutions.

Bisi Williams  6:55  

So I love how you have that comprehensive view of business, of academia, of culture, which really gives you a holistic point of view, and I'll forgive you, I'm not a designer by formal training either. But I like to think that everyone is a designer, if you have a vision, and you want to shoot for the stars that you can systematically get there and that's the methodology. So I'm really excited to jump into the fray with you here. Now we can move into the future. I'd love for you to share with our listeners your vision for health and wellness in the year 2049.

Marco Bevolo  7:33  

Well, in the year 2049, it will be for sure, a completely different context. If you want to see a glimpse of what health care and wellbeing will be in 2049, you should take into consideration that we already see the senior citizens and the middle aged citizens of that time and they are the millennials. So basically, just like baby boomers and Generation X to which I belong, developed in their own path of values, beliefs, so, it will be the case for the new generations and for the millennials. I think what we will see in terms of demand, it will be more and more an evolution from the definition of sick care of addressing symptoms of measuring by output, number of events with a medical machine or number of patients to value-based care, where actually the measurement is based on how efficient and effective the treatment is. There will also be plenty of technological change. If you think about medicine at the time of Rembrandt, when the sort of military medicine was invented, in terms of being present in the field of combat. If you think about the evolution of how we regard all sorts of emotional mental conditions that were considered sickness 100 years ago and now they are completely redefined by new epistemological philosophical definitions. There you'll see the possibility for health care to really change its face. And while that's a little bit of the school in terms of futures that I have experienced, which I believe will happen by the crossing of the technological roadmaps, possibilities that come from science and from digital technologies, values and evolving social cultural values in context. And, of course, I don't like to speak about business models in the case of care because I'm a very strong believer in universal health care.

Bisi Williams  10:38  

I think that the vision that you have for the future in 2049 is quite amazing, I'd like you to actually just take me back to 2049 with a progression or a digression of things and events that can happen in our life that will get us to this terrific state that you're talking about.

Marco Bevolo  10:58  

Well, thinking by means of roadmapping is relatively easy. We do know that there will be stages and there will be different events happening. So it's actually quite accepted that in 2049 singularity will happen. So machines will think and will behave in a way like the human mind does. We should always accept the technological advancements and the scientific possibilities that are derived from these kinds of roadmaps of possibilities that are extrapolated almost by reflection. I think that technology will be definitely, it's almost impossible not to mention a driver of the future health care, from the digital tweaks that will offer possibilities to treat the heart, for example, to treat cardiac conditions to simulate whatever sort of invasive intervention to all sorts of artificial intelligence, virtual reality, and so forth. So if you look at nuclear medicine, if you look at the advancement with robotics, that's a whole world that goes from telehealth to wearables for monitoring to very specific machinery. But I have to confess I don't see that side of the equation as really fundamental. I see more the human factor in terms of social cultural values, in terms of evolution of beliefs, and the evolution of mindsets. For example, I see that it's becoming more and more common for millennials to bring mindfulness into the picture. And I think that mindfulness, we have seen together with Filiberto Amati in our recent series of interviews on the future of events, mindfulness will become a very important reference, for example, in business schools like design thinking has become in the last 20 years. I can think that with mindfulness a different approach, a more holistic approach, a more wellness-based approach will be injected into the definition of what healthcare is just as an example, and at that point, all the technology that you have available, will be geared towards a different purpose towards a different set of expectations.

Bisi Williams  14:26  

Tell me more about the different set of expectations. I love where this is going.

Marco Bevolo  14:31  

Yeah, well, in a way, the way we perceive the world is very much geared to our systems of beliefs. And actually in a conversation I had with Bruce Mau, a few months ago, we were discussing how the kind of cosmology of First Nations of American natives really offer a completely different opportunity to evaluate the meaning of our presence in the world, the function of humans on the planet, and the necessity to keep a totally different, balance with the environment we have around. This is just an example to show it's not necessarily that we live by Western values. We can consider alternative ideologies, alternative epistemologies to give the interpretation, to what actually wellness is, to what your condition is, whether it's a good condition, or it's a sicker condition and what the solutions are. Of course, a science is a science, I have conditions that require medications and medications are chemicals. That is very much objective. What is way less objective is the system that defines me as a person with a condition. What are the roots of this condition, what are the remedies, and what can restore balance between me as an individual and the world outside? I don't want to sound mystical, but I think this is going to be quite fundamental in determining the choices we make about the systems that deliver health care. We have seen very big changes around the notion of what is being considered sick, or being considered healthy and this is depending on philosophy from ideology. I'm a very strong supporter of the idea of universal health care. And in that sense, also, in my conversation with my friend, Chris Bevolo, he interviewed me for his book about health care in 2030, I came across as a bit of a socialist at times for American standards, but it's not about being a socialist, it's about seeing where the maximum benefit is over the longest time. Universal health care guarantees the best individual happiness, which is fine. But it also guarantees the best social stability and the best prevention, the best functioning of society around the notion of treating people in need. I think you'll see the example of COVID vaccination. It is no point to distribute the vaccine to advance the economies of so-called advanced economies, and leave a couple of continents behind because then the virus will continue to circulate, you really need to address it and to think at a planetary level. And that's what I find really important at this stage to think about health wellbeing beyond the fact that if I am a billionaire, I have access, I can buy myself an MRI unit, and I have it in my basement in case I need it. We should really go beyond that and think about the collective condition and general wellbeing.

Bisi Williams  19:11  

I think that's interesting, where you're going with this around the philosophy of health. You talk about health as a cultural concept and could you define that a little bit in terms of how you see the evolution of health in 2049, and then wrap that around what we discussed as a major redefinition of what design is and what is the ambition of design, in terms of how we can look at impact to change or make better systems in the year 2049 as you describe them in your vision.

Marco Bevolo  19:53  

Well, first of all the year 2049 is really ambitious for a forecast because normally the forecast is five to 25 years. So you're really stretching to the limits of where foresight can effectively deliver scenarios. In terms of health care, I think that the notion of health care will be value-based and focused on the actual treatment and anticipation. It's very important to think in terms of cycles that are not the cycle of symptom, treatment, betterment or a cure, and going back home, but the overall wellbeing with an increasing awareness on food quality for impact. If you think about the possibility of having digital technologies to actually deconstruct what we normally used to have as a concentration, it will have a huge impact on the distribution and availability of health care. You can think about smart hospitals, walk-in clinics in rural areas, in areas previously underserved. You can think about virtual reality and artificial intelligence adopted for remote surgery. You can think about millennials growing up and eventually parents becoming grandparents, and not giving up the fundamental values. So that perhaps resembles the hippie mentality of the 1970s. The digital natives are really nomadic and if you look at the demographics, it will also be a very split health care because we will have countries which are the current advanced economies, so we are talking about North America, Japan and Western Europe. In these countries, you will have health care that will address more and more and it's already the case for senior citizens, but you will also have regions like India and Africa, that will be actually booming with a younger population. And there you have a totally different set of needs. So demographics, we probably split the notion of what health care is. But ultimately, I also think that health care itself, if you look at it from a cultural perspective, does not necessarily belong in 2049 to the same black box where we put it in the last 100 years. I'm thinking really about the evolution that psychology endured in the last 100 years. So I'm thinking about the way mental health is being redefined and the possibility will be there to anticipate much more to prevent, to invest in quality of life. The real divide is the fundamental choices that people will make at a political level, because the way health care is administered is very much depending on the sort of organizational model that is used for the delivery and for the provision and for the definition. I wonder if business parameters are really needed to apply to health care and I wonder about a yearly checkup or in the year 2049, the investment in a digital twin, in genetics, in prevention. Isn't it better than running a benchmark on how a symptom-based sick care business unit is managed? So that's the change that I envision in terms of systems. I think it will be necessary for millennials, as they grow, to rethink the system they have around and incorporate mindfulness, sustainability and all sorts of different values into those systems by means of politics in the end and redefine as such the meaning of health care and the meaning of wellbeing.

Bisi Williams  25:33  

That's fascinating, I have a question for you because I want to know, why are you confident that this idea, this vision that you have can be achieved within 30 years, looking at politics, or how do you think that's going to happen to have that high touch wonderful experience that you described?

Marco Bevolo  25:52  

Well, you mentioned design and I'm a big believer in design as a force that changes the world. Design thinking is very much pervasive these days, it's everywhere, I think that will be an agent, to redefine and to address the possibilities that will come from the new technologies. So I see in this connection of design thinking and design, to rethink, through design, our relationship with the world. I see a fundamental aging that will be increasingly capable of valorizing technological opportunities. I also see the new generations, perhaps, I meet a lot of students in their early 20s and I have the impression that they are more and more politically-oriented, but through a new definition of politics. I see a lot of engagement for collective wellbeing, a sense of the need to redefine, rebalance society towards a more just and more fair distribution of wealth, distribution of power. I'm a bit sometimes skeptical on some manifestations, but the fundamental direction I see is a positive direction with the current movements, inspiring and inspired by the youth to achieve massive change, because that's what they ultimately demand.

Bisi Williams  28:04  

I'm also hopeful too, and I love that while you look at the world with straight eyes, you can also see a bit of optimism here and I wonder from these ideas that you describe and your bullishness on the youth and design as a driver for change for all these complex problems, how do you think the scenario that you're painting will make the world a better place?

Marco Bevolo  28:28  

It's a preferable scenario. I published the book in 2009 and it was reviewed by a guy who is teaching innovation here in the Netherlands. He was quite critical because it was not an academic book. And he wrote, Mr. Bevolo was not a doctor, yet, Mr. Bevolo is a zealot. This is a book for zealots, Mr. Bevolo seems to be one of them. And at the time, I was not happy. I only got one review, and it was not very appreciative. But my students loved it and I'm still quite proud that I wrote it. So the thing is that the kind of scenario that I described, it's really looking at a form of health care that changes into anticipatory holistic, seamless care and really leverages these values for the redefinition of our place in the world according to sustainability. Of course, you can also sketch doom scenarios. You can think of a future where you'll have leaders who think about exploiting forest areas and building new highways. You can think of all sorts of doom scenarios, which is possible.

Bisi Williams  30:19  

But that's somebody else's show, that's not our show. 

Marco Bevolo  30:22  

Yeah. But I like to point that out, too, because it's a choice and that's also what I try to always tell students, because students in general, their first intuition is that a designer is somebody who makes beautiful clothes or beautiful objects. And I try to explain to them, and following Vilem Flusser and Tony Frey, that the designer is actually the lady or the guy who makes everything in the material world around us. So fundamentally, a designer has the choice to design the most beautiful package for the most toxic product, to design the most elegant weapon that is going to kill 1000s of people, and that's why it's the best weapon, or to make a positive impact and to really pursue change. What I have seen is really an increasing ability of younger generations, not to pick the older ideological systems, but to grasp or synthesize the essence of our challenges. If you have a weather crisis you cannot think in individualistic terms when there is a storm that destroys half of the city in that sense. Perhaps I'm not generally considered an optimistic person. But I am quite optimistic about these new generations, younger generations, because I see a lot of drive to change inspired by the necessity of the environment. I'm very nostalgic of the 1960s, but  that's related to my age and my sense of aesthetics. I think that anchor will be part of a revolution that will not use weapons, but will use ideas, will use a vision, and will use design to really make a difference, and to really redefine who we are and what we do on this planet.

Bisi Williams  33:15  

That's beautiful. I want a future that has art, science, technology, and beauty. And I love how you equate all of those things and look at our future, which actually allows society to work at their highest purpose in a way of thriving and beauty. I enjoyed our conversation. I appreciate you sharing your bold vision and it's been an absolute honor speaking with you today. Thank you for coming on our show.

Marco Bevolo  33:56  

Well, I am delighted and we can do this again. anytime soon. I'm very thrilled to contribute to the conversation and sure that there will be opportunities to inspire each other in the future. Thank you very much.

Bisi Williams  34:17  

100% come back anytime. So that was Dr. Marco Bevolo sharing his vision for health and wellness in the year 2049. If you enjoyed our show, please rate, review and tell one friend about us. Thank you for listening. I'm your host Bisi Williams, take care and be well.

Mari Velonaki, Professor of Social Robotics, University of New South Wales, Sydney

How will robots evolve to assist individuals with health and wellbeing in the future? Mari Velonaki, Professor of Social Robotics, University of New South Wales in Sydney, envisions a future where technology coevolves to enhance humanity. One of the world’s  preeminent thinkers in robotics, Mari’s work emphasizes creativity and playfulness in design, advocating for a shift from mere utility to personalized, transparent and ethically-driven solutions. Drawing on the concept of “coevolution,” her approach highlights the organic and synergetic possibility of society and technology evolving together. 

Mari Velonaki is a Professor of Social Robotics at the University of New South Wales, Sydney. She is the founder and director of the Creative Robotics Lab (Art, Design & Architecture UNSW) and the founder and director of the National Facility for Human Robot Interaction Research (UNSW, USYD, UTS, St Vincent’s Hospital). Mari is a Research Leader at the UNSW Ageing Futures Institute. 

Professor Velonaki’s research is situated in the multi-disciplinary field of Social Robotics. She holds a PhD in Experimental Interface Design (UNSW 2003). Velonaki began working as a media artist/researcher in the field of responsive environments and interactive interface design in 1997. She pioneered experimental interfaces that incorporate movement, speech, touch, breath, electrostatic charge, artificial vision and robotics, allowing for the development of haptic and immersive relationships between participants and interactive agents. In 2014 she was voted by Robohub – a large robotics community of researchers, educators and business – as one of the world’s 25 women in robotics you need to know about. 

Mari’s contributions in the areas of Social Robotics, Responsive Systems and Human-Machine Interface Design include: 

• Created novel interfaces between a human and a robot that include the modalities of movement as body language, touch as an encoder of human emotion. 

• Created interactive robots that are of human scale and have substantial presence in the physical world. 

• Introduced open experimentation whereby robots are placed in public spaces and not tested only in laboratory settings.  

• Velonaki has assembled two of the world’s largest datasets (over 690,000 recorded interactions in 13 countries) in human-robot interaction (HRI) studies that provide valuable information on the qualitative dimensions of human-machine interactions. 

She is the recipient of several competitive grants and has collaborated extensively with industry partners in Australia, Japan and the United States. Mari’s robots and responsive installations have been exhibited worldwide.

Show Notes

• Mari Velonaki shares her background in interaction design and robotics.[03:46]

• What does a human centric vision for the future look like? [05:23]

• How can technological systems evolve to support us in the future? [08:11]

• What is the coevolution of assisted robots? [11:58]

• Should robots be human-like? [15:29]

• How can humans and robots move from coexistence to co-inhabitation to coevolution in 30 years? [18:50]

• Developing new technologies that enhance our humanity. [23:10]

• How can generative assisted robots improve the quality of life for those with disabilities or special needs? [25:38]

• How can robots be tailored to meet unique individual needs? [30:03]

• How can we address ethical considerations and potential challenges associated with generative assisted robots? [32:34]

• What would the world of assisted robotics look like without art? [34:52]

Transcript

Bisi Williams  00:04

I'm Bisi Williams, you're listening to Health2049.

Mari Velonaki  00:09

To me, my personal vision is systems that don't copy something, why do we need to copy another human. We don't believe in relationships of replacement. The worst thing that can happen, at least to me, is to have a mini me. My approach for health and wellbeing is very human centric, evaluating current systems and developing systems that are relevant for people's ever changing needs.

Bisi Williams  01:50

Hello, my name is Bisi Williams and you're listening to Health2049. Have you ever imagined interacting with robots that respond to your touch, speech and movements just like a human? Well, this is not just a figment of the imagination, it's the reality of social robots, an interdisciplinary field that combines computer science, engineering, psychology and sociology. This innovative field has the potential to revolutionize human life and is already being used in healthcare. One pioneering figure in this field is Professor Mari Velonaki who has been voted one of the world's 25 Women in Robotics that you need to know about. Her research has broken new ground in the development of haptic and immersive relationships between people and interactive agents. And her work is not confined to the lab. In fact, she has introduced open experimentation by placing robots in public places, collecting valuable information on the qualitative dimensions of human machine interactions through the world's largest datasets, with over 600,000 recorded interactions in 13 countries. Mari Velonaki is a professor of social robotics at the University of New South Wales in Sydney. She is the founder and director of the Creative Robotics Lab. She's also the founder and director of the National Facility of Human Robot Interaction Research and Professor Velonaki is a research leader at the University of New South Wales Ageing Futures Institute. Get ready to be inspired. It is my pleasure to introduce Professor Velonaki, welcome to Health2049.

Mari Velonaki  03:33

Thank you, Bisi, oh, wow, what an introduction. Thank you so much for your kind words.

Bisi Williams  03:38

I'm so stoked to have you on this show. And so first of all, Mari, can you tell us a bit more about your interesting background?

Mari Velonaki  03:46

Well, my interesting background. So I started exploring, I guess spaces, technology and interactions with people in the middle 90s. I first started in the area of interaction design. My PhD was in new interfaces. And then I moved into social robotics, actually this interesting, my first postdoc was at the Australian Centre for Field Robotics in 2003, where I designed my first robot fish birth. So this is a mixture of interaction design, moving to robotics and retraining myself in order to be able to move to mechatronic design, technological designer then supervise bigger projects, but I guess my background in interaction design before I even moved to robotics, taught me that in human machine interaction, human machine collaboration, the most interesting part is the human, the most challenging, and I think my research is still the same when I started many, many years ago over three decades, I'm still trying to create interfaces that enhance and improve the human experience.

Bisi Williams  05:15

I think that's amazing. So I'd love it if you would please share with our listeners your vision for health and wellness in the year 2049.

Mari Velonaki  05:23

My vision as I'm getting gracefully older, maybe not so gracefully, I will link it with my involvement within the UNSW Ageing Futures Institute. One of the reasons we started, actually, credit also to Professor Kaarin Anstey, who is the founder and director, but what I found interesting about the health space, it's the approach of a lifelong study and lifelong approach of how I guess we remain healthy and healthy physically, mentally. Yes, we change. As you know, basically, a few months ago, I had a very major robotic surgery myself, which was very different to the kind of robots I work or design. But my vision is really utilizing developing technologies that can be personalized, that they can change based on ever changing needs, that they expand our live space and create more freedom, that we can live at home alone longer, and that we can support ourselves. So it's really about enabling them every day, more freedom for the everyday as we get older and maybe a little bit more vulnerable. But also technologies that change with us, learn from us and become personalized, it's not, when it comes to assistive systems, it's not one size fits all. My approach for health and wellbeing is again, very human centric. So evaluating current systems and developing systems, that they're relevant for people's ever changing needs. Also, the concept of disability, for me it's something really interesting, because we all have different abilities and different disabilities are different parts of our life. So again, creating shared public spaces that not only expand one's lifespace, regardless of special abilities, disabilities, whatever you want to call it, but they invite physical and intellectual, protect safe places that people can experiment and be together, regardless of their abilities. 

Bisi Williams  08:00

So how do you imagine technological systems, how do you imagine that they would evolve and change in the future, how would it really be different for us?

Mari Velonaki  08:11

To me, there are really two things. One is you improve the technological aspect, which is important, and aspects of systems that they learn, that they adjust. I guess the sensory feedback, they understand more about the environment and more about the user. So okay, this is one part and I think we're doing okay, we're growing in this area. But the other part that is also part of my vision, I think there's a gap. It's really the creative aspect, the personalized aspect, the playful aspect, because at the moment when we talk about health or for assistive technologies or supporting technologies, there's a sense of something very utilitarian. And of course, I always borrow the borderies, this concept of the ideological and the mechanical apparatus. You need the philosophical, the ideological and then of course you need the technology to work. So I don't want to undermine how hard it is to develop a system to test them, but that they actually work, they function, but there is another kind of working and functioning and this is how people perceive and experience those technologies. How they feel that the technologies don't drive them, but they have authorship, they own them and they understand them. They're intuitive and they have interfaces that they relate to the users, so it's not like another device that reminds me that my hearing is deteriorating or reminds me that my memory is not at its best, but it's something that I feel, I guess removing, say blandly social stigma. So for me the creative aspect like we were talking about social robotics then being multidisciplinary. By definition we design systems for the people. So it cannot do it alone. But also the creative aspect of it, the design, something that can be also whimsical, regardless of the age group is important. So I think what we're missing is some sort of playfulness and personalization of this technology. So it's not only customization, that people feel that they're happy to use. It's not just user experience, it's not something you just test in the lab. I think that's what I'm missing. And that's what I would strive to see. This approach, it can't be one person's vision, I think it's a shift of how we design assistive systems or systems that they make us feel, provides information, makes us feel more secure in our own homes, longer. It's almost like mnemonic palaces, we don't want systems that remind us of what we're not good at or what we need improvement or health, but systems that celebrate where we are as humans and support us.

Bisi Williams  11:41

I love that. If you talk about this world that we're building, this future state you talk about, how will we move from coexistence and co-inhabitation and coevolution? What does that mean, coevolution of our assisted robots?

Mari Velonaki  11:58

This is really interesting, coevolution, it's almost like a much more organic approach of coevolution to meet as a society, and it's not just technologies there, people are varying between. We all coevolve. First of all it has a more positive connotation that means not just growth, not just greed, not just more, but growing sometimes means understanding that you need less. Some aspects of your growth could be more, some could be less, some needs to stop and some others need to be even more evolved. But it implies synergetic, it's a synergy of things. And it's something that it's not forceful. We all need to be on the same page and move together. With my vision about change and talking about technology, society, culture, it's not only the university in the lab, it's not only industry, it's not only government, it's not only society, it's not only cultural institutions, it's not only politics, you need everything. So this involves different aspects of our society, it needs everyone so to me, also the transparency, the societal dialogue. This is mystifying because at the moment is Oh, the AI will take over, the robots will take over and sometimes I feel the debate. These are very important debates. So we need ethicists and social scientists at the drawing table not afterwards but from the very beginning. Some of my concerns, sometimes we move the debate to the evil machine, the evil system, the evil instead of the decisions and the social responsibility we have. So it's not about the bad decisions. It's not about the evil system. So although these debates are extremely important and the concerns are critical that we need to address to coevolve, we shouldn't be afraid but we shouldn't be also ignorant or optimistic in every single aspect or blind. We need not only to face fears, but we need to be brave in trying to understand what are the issues we need to address.

Bisi Williams  14:41

I think that's interesting because one of the things also in our conversation that we talked about is and this is from your perspective, your of the mind that we don't want to replace humans, nor do they need to be human like, but explain what you mean by that, and coexisting, that creativity, do you imagine it would take on a new form? Or would it be a new life in a way or a new form with its own sentience that's in service? I mean, how do you imagine that? Do you want a mini me, everyone talks about a digital twin. Is that what you're thinking about? But this would be a form of twin of you?

Mari Velonaki  15:29

Interesting. Because, yeah, that's my personal belief, I can talk only about myself and actually the people in my lab. We don't believe in relationships of replacement. The worst thing that can happen, at least to me, is to have a mini me. I don't believe that we have the robots that we deserve in our society. I don't believe that I have designed the best robots I can design. Hopefully not. And representation is very tricky. So although we've learned a lot, and I'm so grateful to all this amazing, of course, we've learned so much from these pioneers, we've learned a lot with our own work. But still, to me, my personal vision is systems that don't copy something, why do we need to copy another human. I just think it's limited. And also there's something about human physiology, that it's so hard to replicate, I would be interested in distributed systems that also have a physical presence, but also that’s distributed, then instead of having a robot going up the stairs, that's a very different task in a home environment, you have a physical agent maybe downstairs and upstairs a representation of that agent. And when I keep talking about physical. For many of our listeners, in robotics, let's put Hollywood aside, unfortunately because people come to me and then they get disappointed and many of my esteemed colleagues, as soon as you have something physical, everything slows down. If you have a digital avatar, everything is faster. Digital gravity, motors, battery distribution, everything's slow. So we have many, many years, we have a gap here, what's physical and what's virtual. So our physical systems are growing, but they're still not quite there. Many times we have the question, why something physical? For my love for the facility you visited, but it's always hard for us, because of course research around the world is based on soft money, as we know. So we love our research contracts and industry contracts. And I'm heartbroken when I have to tell people when they come to me, and obviously we would like another contract. But I have to say I'm sorry, why do you need a robot? And then they realize that they don't need the robot. So save your money, you don't need us, you need something different on a different interface. So many times we don't need a robot, we don't need the physical representation of what the robot is. 

Bisi Williams  18:23

I think that makes sense. And so I just wanted to go back to that idea about the robot and I'm going to ask you this question. But based on what you said we can evolve this question, why are you confident that your vision of humans and robots moving from coexistence, to co-inhabitation to a state of coevolution can be achieved in 30 years?

Mari Velonaki  18:50

Okay, I want to be confident. I link it back to what I started to say before my very long background. But still, there's something very, very special, just to link it back to why we need physical systems. There are many occasions that we don't, but there's something very special and I'll go back to kinetics, when you have something physical that you share a room with. It's very different from having something virtual. There's something almost magical about having this physical, tactile representation of something. So although it's not good for everything, I still think that these future robots, and please let's try to imagine that there are objects of the future depending on the use, so it's not one robot, one use, one system, they can look very different. I would be happy with robots if they can change shape, that we utilize new materials that have been developed, distributed networks and materials that allow for amazing computational power that miniaturized within these materials. Neural networks that do exist today, but also materials that are better for our senses, materials that it's not metal or plastic or something just soft. Like they provide amazing tactile interfaces. So they're robots about the future. There's progress in AI and machine learning by a demonstration that different schools, their progress in materials, amazing progress interfaces, network systems, batteries, not so much yet. Motors halfway, but we need to combine them together and we need also to have the creativity to meet, like a creative approach. It's centered around this. It's almost compositional. So yes, I think in so many years I am confident that if the approach is one that it's human centric, that’s not so much human centered, that doesn't mean human centered when I use that it's human as a center what's best for humans. And many times having mean humans or bad replicas of humans, or instead of creating new jobs, replacing jobs, there are very few times that we need to replace humans and that's in jobs actually, that humans should not do. But there are many other jobs for evolution to meet that also co-work with systems, not that the system is going to take over my job if my job is a satisfactory job, but also creating new jobs. So that's why it's a much bigger conversation between government, society, universities, industry, it's multi-partnered as well. But this vision of coevolution, it's a new compositional exercise, if you wish, that it's not a robot, there is not a distributed system there. It's not the museum, art museums and culture don't need me or don't need justification. They exist on their own, that have been existing for 1000s of years in different cultures around the world before institutions as they need to evolve in experience of your environment, in your society, in yourself. But I think that part of that aspect of co experience, coevolution, enhancement, it's missing. 

Bisi Williams  23:01

I love that. And so tell me Mari, why is your idea and vision important? And how does it make the world a better place?

Mari Velonaki  23:10

I don't think it's only my idea. And if my idea is important, time will judge, I'm very passionate, but I don't know if it's important. I'm not comfortable saying this is important. It's important to me, if I die, contributing 0.0005 of someone's experience, if a person feels more human, so to me what's important, it's developing technologies that enhance our humanity. Humanity is the core of it, it's not machines that make us more machinic and it's not systems just for convenience or increase for profit. There's nothing wrong about increasing your profit for companies, as long as we create jobs but the other things in there. So to me it's about, we develop systems and we develop a society but we cannot partition this is the technology, this is the AI, this is robotics. We can see it only as a product development. You know what, a great product is wonderful. I'm not against the product. I'm not against the industry, I'm the very opposite. I don't believe that this is one box and this is another box. It's like we need to work together. But really, it's about creating systems that are relevant to our current and future needs, that they learn from us, that they don't dictate us. We don't want the kind of interface for a middle aged woman that says I need to struggle. It reminds me how slow I am, and where are my glasses, and 10 years from now, it's going to be even harder. The context that we design is important. But then the learning of the systems and the ability to learn not like a big brother, big sister, whatever you want to call it, it's like learning from you and protecting your data and move along with you is important in order to be accepted in our society, otherwise, they're not going to be used. 

Bisi Williams  25:38

You're absolutely right. And I would love it, if you would share a bit more about how generative assisted robots can improve the quality of life for individuals with disabilities or special needs, for example.

Mari Velonaki  25:53

This is what I was talking about before, this is an area we're working on and I want to see results in the next year because practically there's nothing there. It's so little, it's really, so again, it's so little in terms of risk. It's a lot of research, but I want to see the application. The difference about this kind of work and I say it's so little, it's not just based on lab experiments, I want to see the difference. I want to see this system implemented with society. It was wonderful and thank you so much for your truly amazing introduction about my work, I hope I deserve 5% of that. It is true, yes, we have the biggest data collection in the world from 13 countries, in public spaces, in major museums of how cultural robotics or robots interact with people in a shared space. And we've learned a lot. But you know what, no one has, including us, long term data. I want my system to be used, to be implemented within users, not an experimental phase for two years, for three years, for four years. And then understanding, do they make a change? Do they adapt? Are people happier using them? So my vision for the next, let's say, five years is for these technologies to start being implemented outside of the labs, to society, via industry and government. And there's so much, I'll give you an example. creating spaces with systems that they take into account people like myself, listening to very loud music in the late 80s and 90s. I guess I'd be deaf I'm sure, according to my daughter, yes. We all have different disabilities. There's not one person who gets to middle age who doesn't have, from wearing glasses to hearing to people maybe that need different places, shared social spaces that they cater for also emotional regulation. And there's so many things we can do that with sound, with olfactory stimulation, with robots that respond to people with different needs, or they don't exist in the public domain, that they're not the boring robots. I'm sorry, we don't need the robot to serve me food in a restaurant, honestly. I mean, it's entertaining, it’s great and also kudos to the people that develop the systems because for a physical robot to move around to carry things to hand over things, it's a lot of work. And this work is not wasted, navigation sensors grasp, we can use all things for so many areas. But to me, I’d rather have robots that actually don't look like mini humanoids. They're not metallic. They look more like kinetic sculptures. They could be used in public spaces to assist people. They develop not only with one disability in mind, but what happens if someone is blind? What happens when a robot approaches someone who cannot hear very well? What are the modes of communications we have there? So, to me, it's multi modes of communication. Back to communication, there's so much work about speech recognition. It is very important, of course, for how robots can communicate. But there's so many non direct modes that we haven't explored.

Bisi Williams  29:45

In what ways can generative assistant robots be tailored to meet the unique needs and preferences of individual users? And are there any limitations or trade offs in customization. 

Mari Velonaki  30:03

There are limitations now, but if we talk about the future, it should not. And I think the customization is beyond personalization. I know someone will say, Oh, yes, we can have different colors. Yeah. But it's more than colors. Look, even if we went back 30 years ago, to how wheelchairs used to look and how they look today, and how athletes compete with amazing wheelchairs. It's an evolution. But it's beyond mechanics and colors, when we talk about whatever device, assistive is such a big area. Nursing homes, there are people that we meet with dementia that are always asking the same question, when will our loved ones visit again. How do you have personal objects, wearables for people with their short term memories lost, but they still remember that someone is visiting, but also this social stigma and anxiety. I don't want to ask again, they ask for the 25th time when my daughter will visit me again, when is it going to be the next time. Developing systems that can check, that don't evolve days, for example, if you say to someone Tuesday, someone in that stage, like my late mom, that's it, she would have to ask the question when is Tuesday, what day is today for 20 times, and then she'll be anxious because she knows she forgets. So from small things for people that can easily access themselves, empowerment. As I said the robotic walking frames for someone that could be personalized to a different interface, or they mean something. For example, alert, alert is not just something that tells you Oh, my God, you're doing something wrong, but you can have your own personalized alert. It could be something musical or a change of something that it's only for you, it doesn't need to be a red light, or you're lost, your house is one block away, you took the wrong turn.

Bisi Williams  32:20

That's so beautiful. And I'm gonna ask you, what are some of the ethical considerations and potential challenges associated with generative assisted robots? And how can they be addressed?

Mari Velonaki  32:34

Again, it's like the ethicist should be there from the very beginning. Actually, one of our jobs is also to make sure that working alongside with industry, I'm not trying to demonize industry but we need to advise for things that are not good for us, or when there are technologies that you don't want your data to distribute, or for example, in case of an alert, you have to make plans for your future maybe when your cognitive load declines. Who do you want to get your information? Do you want your kids to get this information? Do you want the emergency, I'm just giving an example. You can decide these things, the same way you decide when you're in a hospital, what's going to happen if this goes wrong. So have a plan about how you want these things and make sure again, government policies protect the people. Privacy of data is important. But then you need systems with networks. Personalization is creating codes that mean something to you. So as a user, you want to have your own identifier, a signifier that means something to you. It's not when that happens, this means and the whole world knows so. We have creative experience, we have playful experience, something that is assistive doesn't have to be only utilitarian.

Bisi Williams  34:10

You know what, Mari, designing the in between and designing the spaces and you're right, there's a whole ton of work to be done. And I think that you've really enlightened me, thinking about how you would design the space for autonomous machines to meet people with different abilities. Currently, it's fully abled bodies. And I think that sensitivity to different modes of being, of moving, of living, of engaging is super important. My question that I have for you is, what would the world of assisted robotics look like without art? 

Mari Velonaki  34:52

Oh, nightmare, I believe art is so central. We talk about multidisciplinarity. We love our museums and galleries and public art and I believe in assistive systems that also created the design without principles. They're going to be better systems. But I wouldn't like to leave my child or our children, grandchildren, the world to live in a place where everything is utilitarian and there's no space for art. Art is in the heart of humanity. For me, it's important that it's not only for what we define as cultural spaces, but they're extremely important in their own right.

Bisi Williams  35:49

Thank you, Mari. Thank you for an amazing discussion. 

Mari Velonaki  35:53

Thank you so much for having me.

Caroline Clarke, Regional Director for the NHS in London

How can cutting-edge technologies shape the future of healthcare by 2049? Join us as Caroline Clarke. Regional Director for the NHS in London, envisions a landscape where AI, genomics and 3D printing lead to personalized medicine. In this episode, explore the transformative possibilities and challenges in financing, restructuring health systems and achieving a balance between standardization and individualized care. Don't miss this glimpse into a healthcare future personalized for every individual.

Caroline Clarke is the Regional Director for the NHS (National Health Service) in London, which leads the NHS’ work in the capital and has an ambitious transformation agenda.

Caroline was previously Group Chief Executive (2019 – 2023) and Deputy Chief Executive (2012 – 2019) at the Royal Free London NHS Foundation Trust since 2019, leading one of the largest teaching trusts in the country.

Prior to this, Caroline held senior positions including as Finance Director at multiple NHS Trusts and as Associate Partner in KPMG’s health strategy team.

Caroline is a trustee of the Healthcare Financial Management Association (HFMA), the representative body for finance staff in healthcare.

Passionate about both the NHS and London, Caroline started her NHS career as a finance trainee in 1991 and has lived in London for 35 years.

Show Notes

• Caroline Clarke shares her background that led to her current position as Regional Director for the National Health Service (NHS) in Greater London.  [03:30]

• What are the two ways that healthcare can transform by 2049? [05:54]

• What needs to happen for new technologies to be productive? [10:23]

• How can we counter the conservative forces that are slow to adopt the use of technology in healthcare? [16:27]

• How will healthcare services be structured in 2049? [18:34]

• How can we achieve the right balance between standardized approaches and individualized care? [22:23]

• How will we finance the healthcare system, especially personalized medicine in the future? [25:59]

•  What role will the hospital play in 2049? [31:20]

• An optimistic view of our healthcare future. [37:10]

Transcript

Jason Helgerson  00:04

I'm Jason Helgerson, and you're listening to Health2049.

Caroline Clarke  00:07

In my idealized 2049 system, actually, a lot of these budgets have come together. Because the more we look at things in silos, the more we have imperfect solutions. So in my mind, we've brought some budgets together, we've started behaving much more rationally about how you apportion resources. And actually, we're starting to tackle some of the big determinants of inequality and ill health by giving people decent accommodation, giving them good education, giving them good food and if there is any dividend from closing those hospitals, that's where it's going.

Jason Helgerson  01:51

Today's guest is an experienced healthcare leader and transformation champion who is now embarking on one of the toughest jobs in global healthcare. Caroline Clark was recently appointed the Regional Director for the National Health Service in Greater London, which means she has been tasked with improving the health and wellbeing of millions in one of the world's most important cities. Prior to taking on all of London, England, Caroline served as the Chief Executive at the Royal Free London NHS Foundation Trust, one of the largest teaching hospitals in the country. Before her tenure at Royal Free, Caroline held senior positions as a Finance Director at multiple NHS Trusts, bringing her financial expertise to the forefront of healthcare management. She also served as an Associate Partner in KPMG's Health Strategy Team, where her strategic insights made a lasting impact. Join us as we hear from a visionary leader, who is now tasked with transforming the healthcare system in the great city of London. I can't imagine a better guest for our show. And I can't wait to hear her vision for health and healthcare in the year 2049. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Caroline Clark to the program. Caroline, welcome. 

Caroline Clarke  03:11

Hi Jason, it's lovely to see you. 

Jason Helgerson  03:13

Good to see you. You've got a very interesting and varied background, many stops along the way that have gotten you to your very important position today. But maybe tell our audience a little bit more about your very interesting background.

Caroline Clarke  03:30

Well, when you introduced me, I started to feel slightly sick in the pit of my stomach, so what have I done? But thank you it's a very, very generous introduction. I'm from Wales, I'm not English. I'm from Wales, which is really important, just so people know that. And that means that I like rugby and I grew up in Wales. Wales is tiny. It's only like three and a half million people there. Whereas the population of Britain, in the UK it's like 65 million. Anyway, I came to London back in the 80s. I read economics and I didn't know what to do with it, but I knew that I had to get a job, I didn't have any money. I joined the NHS because it had a fantastic graduate finance training scheme. And so my background has been financial, but not because I'm a finance whiz or particularly good. I'm okay with numbers. But I see finance and economics as tools to help us make better decisions to run organizations better. And my journey really has been all about trying to do those things, but using finance, and lately I've been in general management, which has been a blast actually, I've really enjoyed it. I've really enjoyed the leadership challenge that being a CEO gives you. I was a CEO during COVID of one of the biggest COVID treatment centers in our country. And that as a non clinician was hugely humbling, very, very difficult in lots of ways. But also, I got to work with some of the most amazing people and I will never ever forget that stuff. So think that those are the big things that kind of really change you as a human aren't they, and probably give you a slightly different insight into what could be possible or what needs to change. So this new job that I'm in NHS London, I've been doing for about five or six months now. And I've gone from worrying about the health of a population of about 2 million to worrying about the health of a population of about 10 million. So London's a tiny bit bigger than New York, but pretty much the same size, and lots and lots of very similar issues. 

Jason Helgerson  05:33

Well great, so you are clearly very qualified for the job you now hold and a job of tremendous importance. And, as we always like to do with our guests, is to give you the opportunity to talk about what you think health and healthcare should look like in the year 2049.

Caroline Clarke  05:54

Okay, so first thing, I'm going to be over 80 and assuming that I'm still here, I'm gonna need it to be like this thing. Because I was interviewed for this job relatively recently and I remember saying, I think one of the biggest challenges we have in the UK and particularly in London is actually it's just quite hard to get healthcare. It's quite hard to access it. It's just not digital, it's really differential, there's tons of variation. So in 2049, I think there will be much less variation or variation that we see will be warranted and it will be there because healthcare will be very, very personalized. I think that whilst we are all living longer and have more morbidity, because we collect conditions along the way, as we get older, we will have done more preventative meds, more preventative action over the next 30 years. So that people like me, will be living longer, but not with three or four competing long term conditions, but maybe just the one. And I will have a really, really good drug regime, which will be personalized, or AI will have got to the drugs that I need much more quickly, because it will have been sequencing and finding the best drugs, so drug discovery will be super quick. If I needed a new organ, it would have been 3D printed. Hopefully, I won't, but it might. I probably won't need much gene editing, but that will be a feature of some conditions. And I suppose the other thing for me is, so I've got two parts to my answer, Jason, one is that I see medicines and life sciences really, really picking up strength and pace on these amazing technologies. So using AI, but also nanotechnology and genomic editing and all that stuff. And then I also see the health systems working quite differently. So in the UK, right now we have general practice, which is often owned by small businesses, it's not particularly well collectivized or capitalized. We find it difficult to put technology into, it's quite small. I think in 2049 general practice, it will be like the kind of primary care that I think you're more used to in the States. The sort of big resource center that you go into that has multidisciplinary teams, you get pulled in if the conditions are worried about you and those systems will just work better. So I suppose I've got the two streams of thought running side by side, and one will influence the other. What I haven't thought about that we might want to talk about is how we pay for all that because of course, by 2049, in my country, we've got loads and loads of old people living longer. And we haven't necessarily got enough young people to pay for their health costs, because the fertility rates have been much, much lower since the 70s. So we've got an economic problem building and haven't figured that out yet. But you told me that I could be optimistic. I'm optimistic that we will figure it out.

Jason Helgerson  09:13

Yes, you are right, the demographic wave that I think at least from my perspective is already starting to come ashore. Here in New York, we're certainly seeing increasing costs in what we refer to as long term care, you refer to as social care are rising just because there's more people who need those services and that isn't ending. As we extend life, those costs will also rise because people will need that kind of assistance and help and we'll need more health care services. But if we could tap in before we go to how we're going to pay, you're very optimistic about some of the new technologies that are really the hot button topics at the moment globally. Things like artificial intelligence and the role that they could play. But it sounds like you're very much the optimist, that it's going to give us the ability to personalize care, transform care, to move upstream and to real prevention and things. Maybe talk a little bit more about why you're so optimistic about these new technologies and what they'll mean for healthcare.

Caroline Clarke  10:23

Yeah, it's a good challenge. So in order to do these kinds of jobs, I'm sure it's the same in the States and globally, healthcare leaders generally have to be quite optimistic. You have to think you can change things otherwise, what's the point? So that's the first thing. I saw Bob the other day, he's back in the UK doing a bit more work. He advised our government in I think 2016 and he talked a bit about electronic patient record adoption in the US and how quickly that had gone, because I guess it was Obamacare that heavily incentivized people to do that. And I thought it was quite interesting and we were having this conversation about whether there's a parallel between AI and EMR implementation. And have we reached a kind of tipping point for AI yet. And then he was very careful to remind us that actually all these new technologies come with problems. So he pointed to the problem of the EMR inbox that currently happened in the States where, as soon as a patient gets their results, there's a little button that says, if you're not sure about your results, go and have a chat with your clinician. You get your result, and it says you've got raise magnesium. And it's like, what does that mean? So hospital physicians now have a massive, massive inboxes full of probably very, very low risk patient questions. And so all these implementations of new systems have to come with thoughts about what they mean and the potential consequences of introducing new bits of policy, like, presumably some very consumerist going on in the States where patients are given their results. It sounds like a good thing, but you need to give them some tools to deal with their results, not just expect it to go back to the poor old doctor. So that was quite interesting. And then he said there was an advertisement for a doctor in an Arizona medical sector center and it had all kinds of terms and conditions and everything of the job and then it says at the bottom as a selling point, no EPR. So there's this real thing about how good is new tech and why is it that new tech doesn't bring productivity, and there's a productivity paradox that we were talking about. And you never see the productivity gains that you expect. The reason why I'm optimistic is because he's got a notion that there are probably two conditions that need to happen to get technology to be pretty productive, and to get better adopted. One is that it just improves over time. I've used Cerner a lot in most of the hospitals that I've worked in, but colleagues that use Epic tell me that the technology now is so much better than it was even a couple of years ago. And these things just do get better once people use them. Those companies are all quite clunky and in the UK we complain about American companies because we have to go through coding changes across the Atlantic and the timezone. But I think there is something about the fast cycle of technological change that happens the more and more people adopt it. And then the second thing, of course, is that you can't just use technology, you need to reimagine the work that goes with it. And if you think about AI and particularly large language models, like ChatGPT, to that point about how quickly is technology changing? ChatGPT is changing so quickly. Bob was giving us some examples, he put a few patient case studies into the AI just to try and get a decent treatment plan for these patients and to test it. And you could see, even in a couple of months, that the AI was getting better and better and more and more trustable as a clinician. I thought that was quite interesting. So there's something about these things moving quickly. And then of course, large language models, things like ChatGPT and stuff are just much easier to bake into existing technology. It's something that's in our everyday life now. So I use ChatGPT a lot, actually. And I've got clinical colleagues that use it a lot, even in conversations with patients, just to make sure that they've covered all bases and so my optimism is that, some people say it's like the printing press. I don't know, that sounds a bit grand doesn't it, being that the printing press totally revolutionized literacy and everything. But there's something going on with these large language models that potentially revolutionizes the way our industry is and it's happening everywhere else in other parts of our life. So my optimism, I think, is founded on that. And whilst I don't fully understand it, and I can see some very big downsides with it, I think it has the power to change things so much that it will just happen. I really do. And what I'm struggling with slightly is I can see how that will happen in the next five to 10 years. My mind is just slightly blown if you want the honest truth for what it will be like in 2049, or whether I'll still even be able to use my smartphone. In fact, we won't have smartphones in 2049, Jason will have something else, we'll just be talking, we're just going to have ambient voice technology. And the clinicians will never have to enter another note into Epic or Cerner again, because it'll all be hoovered up by ambient voice technology and structured into case notes. And the world would be a lovely place.

Jason Helgerson  15:52

I share your optimism, in the sense that, although I am sobered by the hit recent history, or not even recent, but even farther back that healthcare as a sector tends to be much later adopters of newest technology. I mean, healthcare is still the last bastion of the fax machine. The rest of the economy globally has left the fax machine behind, but healthcare and in fact, I think NHS England is the largest purchaser if I'm not mistaken. This was not that long ago as fax machines in the world.

Caroline Clarke  16:27

Yeah, I think we're not now, but I think it took a supreme effort to get rid of them. And we still use pages, I agree. So how do you counter the conservative forces of healthcare? And I think there are a few things, these large language models and other forms of AI and natural language processing stuff are already there and they are being used. I mean, look, even the British government has got into the thing now. So we're recording this in the week where the Prime Minister of England has convened a bunch of people internationally to talk about AI safety. I think that's probably a political move more than a thing that is much more meaningful. And your president has pronounced on safety this week, and the Chinese are doing stuff and Europeans doing stuff. So I think it's there, and it's there in most walks of life. And I do think that healthcare is slower, but I don't know if it's going to be exponential, but it's gonna be pretty quick. We've got to kind of get with it, I guess.

Jason Helgerson  17:29

So one of the questions, just before we get into how we pay for this question, because that's a big one. But I want to talk a little bit about the structure of the health system in 2049, your vision for it, as you mentioned, you have in most developed countries around the world, you would look and the health system, its structures, its locations for where care is provided that they don't differ that much in the sense that you have primary care providers, GPs who are in clinical settings, sometimes those settings are larger, sometimes they're smaller, and then you obviously have as sort of the backbone of the acute care system, the hospital. And I'm just wondering what your thought is, I mean, there's been a lot of focus on trying to move care into the home. A lot of these technologies allow individuals to receive services in the home, the concept which is being implemented as a hospital at home, in the UK, and still early days. But just your thoughts on what you think about how healthcare services are actually going to be structured in 2049.

Caroline Clarke  18:34

Yeah, so a couple of things to say. So just in terms of, organizationally, I am a very, very big supporter of group models. So primary care at scale, hospitals at scale, not necessarily in their structure, but in what they share. So if I think about my most recent experience in North London at the Royal Free Group, we were a collection of three large hospitals where we shared all our non clinical services, we shared an EMR Cerner, we worked very, very hard on the digitization of care pathways in order to reduce unwarranted variation. So that was the thing clinically that held the three hospitals together. And so wherever you got your care, you should have had the same set of pathways, assuming you fit that particular profile. And if you got care delivered at home, it would have been the same as well. So you've got a quality premium there. So I think in 2049, in my mind, there will be more collectivization or services to get those scale benefits. And of course, we're not gonna have enough staff, so therefore, we're gonna need to do these things in order to share our talents more effectively. And to digitize more effectively so that we can take some of the more arduous tasks out of the care system, and I hope I will be looked after at home. I hope that my Apple Watch, which had so much potential until I put it in the washing up and it wasn't waterproof, but it's a bit like the thing I say about AI, the wearable technology is increasing, improving all the time. And you can see that with all sorts of diagnostic monitoring. And through COVID, we did lots more work with nursing homes to make sure that they could really look after patients there rather than having to bring them into hospital. And you talked about hospital at home. So virtual wards for us are a really big deal. With this winter coming now in the UK, I think we won't get through winter nicely unless we have a very, very big virtual ward, home bed capacity which relies significantly on technology. But that will be run out of hospitals, pretty much all out of big community organizations. So again, I'm thinking about my 2049 structure. I don't know if it's the same in the States, but I worry quite a lot about small providers who are on their own who are quite fragile, who could fall over. And so grouping people together and making sure that people get to work across a great set of providers is really a thing.

Jason Helgerson  21:21

The other thing is what I wanted to get at, and get your perspective on is that as you describe the delivery system of the future, you talk about clinical pathways, eliminating what I would call bad variation in how people are treated and trying to achieve levels of aggregation of providers that allow for some economies of scale, so to speak, and some resiliency perhaps, and some redundancy. And so I see all the values of that. But at the same time, I also see this trend with some of the other technologies that I'd like to talk about, personalized medicine and the idea that not all of us are the same, the needs, the right treatments, how we are cared for. What will be the right balance between standardized approaches and individualized care? How do we achieve the right balance between those two and 2049?

Caroline Clarke  22:23

It's a brilliant question because we're struggling with that right now. So I think about the work we did at Royal Free, we were digitizing, I don't know, a fractured neck of femur pathway on the Cerner System, we would specify pretty much exactly what was going to happen to that patient at every point in their treatment from coming to the pre surgery joint school where you learn how to be a good patient, how to rehab well, through to how much anesthetic you're going to get, through to what your recovery was gonna look like and when you'd see a physio. Actually that does sound very, very standard, doesn't it? And for lots and lots of patients, that probably still will be the case. But if you are six foot nine and 85 years old, and you have a very low BMI, then actually that might not be right. And so you have to be able to opt out of those standardizations. This is for those of your colleagues that know Intermountain, this is pure Intermountain. My journey into all this started with a trip to Utah, where we were having a look at their Cerner implementation, and they very generously shared their methodology with us. And then we worked with the IHI on, how do you use QI to improve all this? But you're right, there's always this tension between how much of that is, for me? Most of the personalization I've been thinking about actually is around drug regimes and potentially therapy regimes. So some of that does have a bearing on the process. And I remember we talked to the guys at Intermountain about this way back in I don't know 2017-2018 and they described the tensions then and they saying, Well, they iterate these pathways. And, of course, I  imagined that if you've got a digital pathway on your system, you should be 100% compliant, and they were like, oh, no, no, you don't want anything like 100% because that will just imply people aren't really thinking about their patients and the personalization of the patient needs. So there's a tension that individual clinicians have to live through. And I don't have a great answer, except to say that there will be some patients, the majority who will fit a demographic, which will be the standard pathway, I'm sure. And then there'll be some who won't and that dynamic is going to change over the next 20 years to 30 years. It's really going to change, isn't it? But I don't know how to predict it. And I don't think I should. I haven't got a great answer for you. Actually. I think it's really hard.

Jason Helgerson  24:50

I agree. I think it's hard but I also think it's a huge question to where I want to go next which is cost and how we pay for it because I was thinking about this, individualized medicines, for instance, there's a lot of people with, say, heart disease or chronic lung disease or things like hypertension, where their disease today is managed with very low cost generic medications. And if personalized medicine means that we replace those generics with highly personalized branded, potentially vastly more expensive drug treatments, that only have say, a 5% improvement in outcomes, but it's 50% more expensive, that's the concern I have is that the same time that technology could be our friend in the sense allow us to individualize personalized in ways that lead to better outcomes and ultimately lower costs, or it could just heap tremendous costs onto the systems.

Caroline Clarke  25:59

Yeah. So of course, in the UK, we have the National Institute for Clinical Excellence, NICE, which will need to adapt to take into account the increasing personalization of drugs and therapeutics. So I don't know what the equivalent is in other countries. But this is exactly what NICE is thinking about. And I thought you were gonna say, so what if there's a really, really expensive drug or therapeutic that actually means that you don't have to have I don't know, a heart transplant. So the savings are made somewhere completely different. And therefore the holistic cost. And the whole life cost, actually, probably is, it's better just to have the drug rather than the surgery. So therefore, but actually, you gave a different example, which I think NICE will help us manage in the UK, and I think NICE needs to get into that space. I know they're thinking about it. But the other thing that we have in the UK, which I definitely don't think you have in the States, is the Pharmaceutical Pricing Regulatory Scheme. I think that's PPRS, where they were, effectively, the UK government agrees with the pharmacy industry, a set of prices, which will allow a certain amount of research and development and pipeline to exist, as well as pay for all the drugs that are around at the moment. And that clearly won't work for what I think 2049 is going to look like. So I don't know what you have. Do you have anything like that in the States?

Jason Helgerson  27:30

No, I mean, in fact to great extent, the prices for pharmaceuticals in the United States are much higher than they are anywhere else in the world, which too has a benefit to the rest of the world, in the sense that the US market opportunity for manufacturers is lucrative enough that it basically I think, encourages them to take the risks. So a lot of the drug development cost, it's a high risk business, most drugs that start the development process don't ever get to market, as we know the failure rates are very, very high, 80 plus percent. So as a result, due to the lucrative nature of the US market, it helps to basically fund a lot of that R&D. But I think that, perhaps, back to the new technologies, for instance, if we could create machines, computers that could replace the need for human drug trials, or allow for much quicker drug development or modification, then a lot of that cost could be cut out, the risk could be cut out. And then with that you could bring drugs to market and hopefully at lower prices than what we're paying today. So I don't want to paint a doom and gloom. But I think there's just going to be this tension between individualization and the path we've been on for a long time in healthcare, globally, which is standardization to root out bad outcomes, to root out examples of things being missed, or inappropriate care. I think that's just going to be a tension we're gonna have to grapple with. 

Caroline Clarke  27:30

Yeah, I mean, the other thing I thought we were gonna talk about was digital twins. And I haven't really thought enough about those. But presumably, again, if you can create digital twins for patients, to test stuff out, how do you pay for that? Sorry, I thought some of this stuff through but it turns out, it's quite hard.

Jason Helgerson  29:23

It is hard. But I think what also makes it super interesting and one of the reasons we started his podcast is about trying to inspire people to design a better healthcare system and think about what the needs are in the future. But I want to get to this question around cost and the cost of healthcare and how we're going to pay for this and just what your thoughts are in terms of what you're thinking, or what you think would be an ideal system. And if you have any thoughts on this vexing challenge.

Caroline Clarke  29:59

Okay, so we'll come back to the vaccine thing, but just in terms of how we finance the system, so in my world, I'm gonna need a lot of capital to start everything off. And at the moment in the UK, we just do not have enough capital, it's in the wrong place. And we don't have enough incentives for the big tech companies to load up stuff at the beginning. So we really need to think about that. So in my ideal world in 2049, I would have resolved some of that. And we will have long term partnerships, in my world, Jason, the NHS still exists, right? And we still have socialized medicine, but it'll be organized slightly differently, I'm sure. I mean that's a detail that I haven't gotten to, but we'll have a better way of contracting long term with organizations who are heavily capitalized, who will then want to make the necessary investments into my health system. So that's part of the problem, I think. So I mean, we talked about the drug thing before, that's going to need an awful lot more investment. And the PPRS is going to have to look quite different in the UK to deal with the personalization elements we were talking about before. I think I'm really torn about whether we'll need more estate or less estate, I don't know, do you have a view on that? So, if everyone's being looked after at home?

Jason Helgerson  31:20

Yeah, so it's an interesting question. I personally think that in the year 2049, that the role of the hospital will have been so significantly modified that its scope and its role will have shrunk so much that we won't even call them hospitals, we'll call them something else. And that much of the service, and the people who receive services in that setting will be there for shorter periods of time. And it will be high acuity, and that far more things will be in the home. And so as a result, I mean, that's my hope. And I think the virtual wards, as we call them today, which is really kind of like almost like a version of remote patient monitoring, and staff and resources coming into the home, I think will be a far more common way of delivery. And what does that mean? And it could mean that we are in the business of repurposing hospitals, and other things, maybe it's affordable housing, maybe it's something else that people need more of. 

Caroline Clarke  31:21

Yeah, I was smiling to myself, because of the irony, so the UK Government has launched this new hospital program to build 30-40 new hospitals. And I wonder if that will be finished by 2049? Note to self, check. So I think you're right, so the capital, the financing that we need then will all need to be in technology, and in the training and development of our staff to use it and to keep pace with the changing technology. Because I'm guessing at this point, things will be moving quite quickly, won't they, and I can't really predict, it does blow your mind, doesn't it.

Jason Helgerson  33:10

Think of healthcare now as a very bricks and mortar business, where we go to it, it never comes to us. And I think the future is going to be much more like healthcare comes to us. And hopefully that means it's more personalized in ways that matter. It's more efficient, it's more convenient, it's easier to access. We had a previous speaker on who is the Dean of the School of Social Work at New York University, whose view is on technology was that the gaps particularly for people of color in the United States for access to mental health services is so great, that unless we offer them, in essence, AI-enabled solutions, non human to human, but human and machine type services, we're never going to close the gap. So if we can harness the full power of this technology and we can bring it into the home and we do it in ways that people like and want, we move the system away from a real estate bricks and mortar service too much more of a flexible, dynamic, individualized in the home type of service. 

Caroline Clarke  34:23

But your repurposing point is really important because actually the one thing whenever I talk about technology, there are always people that say, oh, Caroline, but what about digital exclusion? What about people that can't use it? What about people who don't have the language? And then to this point about looking after people in their homes, of course, what if they don't have a decent home? I live in a part of London where Michael Marmot comes from and most health is defined by social determinants rather than by what we do in the health service. And so, therefore, decent housing is really important. So I wonder if in 2049, that will be one of the things that we spend more time talking about.

Jason Helgerson  34:57

Yes, we had an example in some of the delivery system reform efforts in New York where a hospital in the Bronx closed an entire tower and converted it into affordable, what we've referred to as supportive housing, which means you have people who have mental health substance use or physical health issues and services are brought into that housing, but it basically converted into housing for vulnerable people.

Caroline Clarke  35:24

Yeah, I mean all of these budgets have come together because the more we look at things in silos, the more we have imperfect solutions. So particularly in the UK, social care and healthcare are still a bit separate and people like me are trying to bring these things together. The politicians don't want to do it for lots and lots of very good reasons, particularly the kind of demographic time bomb that probably makes nobody want to go near social care for a long time. But I think starting to behave as if we have one budget for in the way that, was that the Montefiore health system you were just describing?

Jason Helgerson  36:06

It wasn't Montefiore, but it was another one in the Bronx that's very similar.

Caroline Clarke  36:10

So we look at that and think, yes, that's exactly what we need to do. So in my mind,  we've brought some budgets together. We've started behaving much more rationally about how you apportion resources and actually, we're starting to tackle some of the big determinants of inequality and health by giving people decent accommodation, giving them good education, giving them good food. And if there is any dividend from closing those hospitals. That's where it's going. 

Jason Helgerson  36:11

Great. So we are coming close to the end of our time. But there's one final question I wanted to ask you, which is, how optimistic are you when we talk about your vision for the future? How optimistic are you that we achieve your vision in the sense that, a lot of challenges in health and healthcare, a lot of challenges from government finance standpoint, a lot of challenges from a geopolitical standpoint, that we will collectively have to overcome, but how optimistic are you that your vision for health and healthcare and 2049 will in fact be achieved?

Caroline Clarke  37:10

Well, I think there's stuff in the Life Science sector, the stuff I started off with really around genomics and 3D printing, faster drug discovery and all that stuff. I think that stuff will happen. I think there's just such a push globally, and there is money behind it. There is a danger, I guess that the regulation slows it down, or there are issues around data, privacy, all that stuff that could slow it down a bit. But I feel pretty optimistic about that stuff. And I have enough colleagues, clinical colleagues that are working on this, I absolutely see that. What is harder, of course, is how we organize it. I mean, I spent my career thinking about how you organize health services and systems. And in my country, the way we organize it is very politically dependent. So I worry that we will go through another few cycles of political administrations in the UK, and we'll never quite get to the right answer. And I say that, I'm very cognizant of it at the moment because it's the pre-election year so you can feel the thing kind of hotting up. But I think we could get close to utilizing all these amazing new, technologically enabled discoveries. We could get close to it. I think it's the system side of it that I'm less clear about. And I think that's because of politics really, rather than from one's who try.

Jason Helgerson  38:38

Well, on that note, we'll leave it there for this great conversation. And that was Caroline Clark's vision for health and healthcare in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.

Sabina Gal, Co-founder and CEO of kahla

How can we monitor our actions now to create a healthy lifestyle in the future? Sabina Gal, an integrative health coach and co-founder and CEO of the kahla app, highlights the importance of every daily choice — including sleep, nutrition and exercise — as valuable data that shapes wellbeing. The kahla app empowers women by simplifying the tracking of symptoms and lifestyle factors. Despite challenges in women's health research, kahla allows individuals to take charge of their health by offering personalized tools for prevention and a deeper understanding of the body. This technology uses the transformative potential of daily lifestyle choices to move us toward a future of longevity and vibrant health through simple proactive steps.

Sabina Gal is the co-founder and CEO of kahla, a mobile app that helps women understand how lifestyle factors affect their health symptoms.

She is also an integrative health coach with a focus on women's health. 

She currently is living in NYC, has studied and lived in London, UK and is originally from Romania.

Show Notes

• Sabina Gal shares her background in technology startups and a health challenge that led to creating the kahla app. [02:21]

• A vision for the future in which we will use data to understand our own health symptoms and conditions. [06:09]

• How does the kahla app empower women? [08:50]

• How can we improve our healthspan? [10:42]

• What is metabolic health and how does it affect women? [13:33]

• Why are women disproportionately affected by a large number of chronic conditions? [14:46]

• What are the pillars of health that we can focus on for a healthier future? [18:53]

• What is the kahla app and how does it work? [22:40]

• How can a continuous glucose monitor (CGM) prevent future disease? [26:04]

• How does a CGM work and what are the benefits? [29:05]

• Every action that we take on a daily basis is data that can help us live a long, healthy life. [31:39]

Transcript

Bisi Williams  00:04

I'm Bisi Williams, you're listening to Health2049

Sabina Gal  00:08

Everything that we do, every little action that we take on a daily basis from the way we sleep, the way we move, the way we eat is actually data. Data that we can choose to inform how our health is going to evolve over time and whether we're going to prevent disease and live long, healthy lives, or whether we're going to have to unfortunately bear the consequences of conditions and symptoms that are going to negatively impact the quality and longevity of our lives.

Bisi Williams  00:45

Hi, my name is Bisi Williams and welcome to Health2049. Today, my guest is Sabina Gal. She is co-founder and CEO of kahla, a mobile app that helps women understand how lifestyle factors affect their health symptoms. She is also an integrative health coach with a focus on women's health. Sabina, Welcome to Health 2049.

Sabina Gal  02:13

Thank you. Lovely to meet you. And thank you for having me.

Bisi Williams  02:17

I'm so excited to have you on the show. Sabina, tell us a bit about your interesting background.

Sabina Gal  02:21

I'm originally from Romania and I've been living in New York for the past six years. Before that I actually lived in London in the UK where I studied and I worked in technology startups for most of my 20s, early and late 20s. After I moved to New York, I actually started having some personal health issues that got me very, very interested in health, particularly women's health. And because I was trying to really figure out my own health problems and dive really deep into what was causing those issues, I decided to get more knowledge and study women's health. And that's when I became a certified integrative health coach. And a few years later, because I was trying to really get to the root of my unexplained and weird symptoms, I started building this massive spreadsheet where I was tracking a lot of different factors and a lot of different symptoms and trying to find patterns and correlations. And after about, I want to say six to nine months of daily tracking, I had this massive, massive amount of data in front of my eyes. However, it was very difficult to be able to actually see patterns and correlations. And so I had this aha moment when I thought to myself, okay, there has to be a better way to do this, a spreadsheet cannot be the only way or the best way. And I thought okay, what if we had an algorithm that was able to take this kind of large amount of data and look at the different correlations and patterns and then give you a simple summarized overview of what could be causing symptoms. And what was interesting is that at the same time, my sister, I have a younger sister who at the moment lives in Bucharest, Romania, she was also dealing with some health issues. It was through this process that we actually discovered that we have some autoimmune conditions that run in our family. She was struggling with a very different condition, but very, very similar in terms of having unexplained symptoms that would just flare up and she could not put her finger on what was causing the symptoms. And so she was using the same kind of spreadsheet method for tracking what was happening and we would both have calls and compare notes and try to share what we were learning and because we were doing it at the same time and because we became so invested in this process, we decided that we should start our company together. 

Bisi Williams  02:28

I love it, that sisterhood. Now, I'm sorry that you have this ailment, but I want to touch on something here. I read recently in the New York Times a huge article about the huge mysteries of women's health. And I'm thinking we're 51% of the population now. In 2049, 30 years from now, we'll have solved this generally, like women's health and symptoms and issues won't be a mystery, which I'm looking forward to. But it astounds me that with all of the knowledge that we have, that there isn't a systematic way of looking at what is ailing women. So I love the idea of the company that you've started with your sister, and tell me based on what you know now, 30 years from now, can you tell us what health will look like from your perspective?

Sabina Gal  06:09

Absolutely. So I think 30 years from now, we're going to live in a world where individuals have a lot more control over their health, and the data is with the individual. I think part of the reason why so many women struggle with health issues that are not easily identified or easily solved is because we are used to giving control and giving the rest of the responsibility for our health to external sources, like doctors in the medical establishment. However, doctors and the medical establishment are not incentivized to spend hours on end to try to get to the root of our symptoms. The way the system works and the way they are incentivized is to find the quickest, fastest, easiest, most affordable solution to or not necessarily solution, treatment, I should say to a problem. And that doesn't always necessarily solve the problem, it can mask the problem, it can make the problem feel less bad in the moment, but it doesn't necessarily get to the root of what is causing the problem. So in 30 years, I think with the help of technology, and with the help of technology making tools that are very easy to use, and affordable, and putting those tools in the hands of actual consumers and patients and in people in the general public, we will have so much more information about our own bodies, and a much better understanding of our own bodies. And an easy way to gather data over a long period of time in order to be able to really go deeply into understanding what is causing symptoms and conditions. And so we are not going to rely so much on a yearly visit to the doctor that lasts maybe 10 or 15 minutes, in which of course, you cannot even begin to get to the root of so many of the conditions and symptoms that women struggle with today. 

Bisi Williams  08:05

You know what I find interesting about your vision, and just the story between you and your sister is that you were comparing notes and that you had the wherewithal to look at your symptoms and recognize that something was wrong, first of all, so trusting your own bodies. Two, actually understanding that something is not right as you understand your condition. And then three, the ability to compare notes. I'm wondering, in your research for your company, if you just found that all the compendiums of medical books and science and the pedagogy at school perhaps doesn't actually have a comprehensive database, if you will, or information about the experiences of women and their bodies? I'm just throwing that out there. 

Sabina Gal  08:50

No, you are actually absolutely right. It is a huge problem. And it is a very well known problem, at least in the medical field, not necessarily by the general public, that in most studies, most clinical studies and randomized control trials are done on men, not on women, and even those that are done on women, very often they exclude women of color, minorities. So you have a huge gap of data when it comes to having the science and literature on women's health. There are a number of actually, many treatments and solutions that were only researched on on men, not on women and so that's why for us kahla is very important to empower women to really understand their bodies because oftentimes the solutions that we'll be presented with might not work very well for you because they were not designed to work for you. They were designed to work for 35 year old men who might have very different needs than let's say, a 25 year old woman who at the same time I have very different needs than a 45 year old woman who may be going through perimenopause, and is experiencing a completely different set of hormonal changes that need to be addressed in a very specific targeted way.

Bisi Williams  10:13

I find this interesting. So, we're talking about design here and how you're looking at it from a comprehensive view in terms of taking all of the complexities of women's symptoms, and women's health, and putting it in an app. And I'm curious to find out with this citizen science, how do you imagine it will coalesce with a, let's just call it textbook medicine?

Sabina Gal  10:42

Well, I think again, we definitely need to textbook medicine. I'm not the kind of person to dismiss Western medicine and for so many different reasons, you might end up needing to have care in a proper hospital and being surrounded by a team of doctors. And that is absolutely essential. However, when we talk about prevention, prevention is not something that happens in the doctor's office and prevention again, it’s not something that happens during your annual visit. Prevention is something that happens every single day, and the individual is much more responsible, but then maybe we were educated to believe that we are about taking care of our longevity and taking all the preventative measures that we can to ensure not only that we don't get sick, but then we actually get to live a long healthy life, because you have, of course lifespan, but you also have health span. And health span is actually just as important. It's not enough to live to 90 years old if the last 20 or 30 years of your life are terrible, because you are in a terrible health condition. And so I think where those two intersect is at the individual level where through your lifestyle choices every single day, you can make really important steps towards meeting your medical team halfway, because it's one thing to end up needing to have to be taken care of, and to have treatment and medication for different conditions. But if you're actually taking the proactive steps, to be in good health as much as possible because you're never going to be able to control everything, you are going to get to a place where you're going to feel a bit more empowered. And you're going to feel like you do have at least some measure of control over your own health and our app is mostly focused on very simple lifestyle tools. Because if you look at a lot of the chronic conditions that plague not only women, but actually a lot of Americans and a lot of the world, for most of those conditions, lifestyle interventions are actually the first line of treatment, before medication, before any kind of big intervention surgeries or anything like that. It is advised to apply different lifestyle modifications in order to even reverse certain conditions.

Bisi Williams  13:20

So I love that. So tell me more. I mean, I'm completely tracking with you. And tell me why is your idea and vision important? And how does it make the world a better place?

Sabina Gal  13:33

So if you look at some of the data on women's health, actually, women account for more than 70% of the people affected by certain conditions such as autoimmune conditions, chronic pain, hormonal imbalances, even things like digestive issues and stress also affect women twice as much compared to men. And then you have metabolic health, which actually is a huge problem in our in the Western world right now because so many people suffer from metabolic dysfunction. And that can be pre diabetes, diabetes, heart disease, which is actually the number one cause of death in women. A lot of women actually fear breast cancer and for good reason, but fewer women know that heart disease is the number one killer for women. And if you are in poor metabolic health, that increases your risk even more.

Bisi Williams  14:27

I didn't know that. Those numbers that you're sharing with us Sabina, 70% of people have chronic pain are women and hormonal unbalances.

Sabina Gal  14:41

And autoimmune conditions. Yes.

Bisi Williams  14:44

And so tell me more.

Sabina Gal  14:46

Yes. So the reason why that happens is again and I'm gonna go back a little bit to what I was talking about before, which is that women go through so many hormonal changes. So you have puberty, you have your reproductive years, you have menopause. And whenever those changes take place, everything in our body gets more susceptible to different shifts that might not necessarily be positive shifts. And so there are certain conditions that just simply affect women disproportionately because of our different genetic makeup, and because of those different changes that we go through throughout the different phases of our lives. And so then even for women, if you look at, let's say, you take something like type two diabetes, which unfortunately is on the rise, if you look at that, women compared to men, women who develop type two diabetes by age 40, they will have a two fold increase of heart disease compared to men. And if you look at something like dementia, or Alzheimer's, women outnumber men two to one worldwide and more recent studies have discovered that actually, Alzheimer's is highly correlated with poor metabolic health and blood sugar imbalances. Alzheimer's is actually now called type three diabetes. And so because women are so disproportionately affected by a large number of chronic conditions and you couple that with the fact that a lot of women actually feel dismissed or have their symptoms then downplayed by doctors, that makes it so imperative to give women tools for them to be able to understand their own health, not just to understand it, but to actually track it over time. Because we're now in 2049 and you have been given tools, tech tools that are affordable, easy to use, that you have them daily in your pocket, because we all have access to a smartphone, at least in 2049. Probably a much better, smarter smartphone than today. And you'll be able to track those changes over many years. And let's say you're a woman in your late 40s or 50s about to enter menopause, you have actually been able to track the slight, but daily shifts and changes that have been happening to you for the past, let's say 20 years, every single day, and you have so many data points that have taken you to a place where you have a very deep understanding of where you started from and where you are right now, and how you can manage all of the changes that are yet to come. And again, it's all about those small lifestyle interventions that you can do every single day, in order to be in a more prepared position no matter what life is gonna throw at you and as a woman, unfortunately, you can be sure that you are gonna offer it at one point or another. That is the sad reality.

Bisi Williams  17:52

Or you have the joy of change. I wanted to just track something here that I think is really interesting based on your data. I read a study that millennials, that lovely generation that is carrying forward the rise of diabetes, it's unprecedented in that demographic and if you're saying that by 40, let's just say that the rate of increase for diabetes is happening. And you can start to imagine our future, that if we have young people with chronic conditions today, what does that bode for our health system, if you will, in 2049, 30 years from now, and I love this idea of prevention. And so what in your opinion are some of the small things that women and people can do today to turn the tide? 

Sabina Gal  18:53

Absolutely. So I'm really glad that you're bringing this up, because I’m afraid to imagine if we continue at this rate what the burden on the medical system would look like in 2049. The system is overwhelmed. We are spending an enormous amount of money on trying to fix conditions and problems that could actually be prevented in the first place or reversed through lifestyle modifications. So I think the three things that if every person on this planet would do more of, we would be in so much better shape and they sound very simple and they sound very silly but they are so important. Number one is sleep. So many people don't pay enough attention to sleep. They either don't get enough sleep or they get poor quality sleep and sleep is so important. It is vital for our long term health and well being and we need at least seven to eight hours of sleep and a good quality sleep. That's number one. Number two is what we eat and here of course we can go very, very deep into nutrition and you can go very far into making lots of different kinds of choices. But the number one thing is to really try to limit or eliminate completely processed foods, because processed foods, unfortunately, are what is driving a lot of the metabolic crisis at least in the United States right now. And people are not aware that a lot of the foods that they are eating are highly processed, but if you go shopping in a grocery store, it's all the stuff that fills the shelves, if you walk in a supermarket, you will usually notice that all the produce is concentrated in the middle of the supermarket, and then all the aisles are basically shelves filled with packaged processed foods. So the number one tip here would be to always stay within the center of the supermarket and shop there because that's where you're gonna get all the healthy, amazing foods that are going to nourish your body and protect your body. And then number three, and again, these are all equally important, but I think they're the pillars that are the foundation of health and longevity and prevention, number three is exercise. Very sedentary lives, we spend most of our lives sitting at a desk in front of a computer, we don't move our bodies not nearly as much as we are designed to move our bodies because we are not designed to sit for 12 hours a day and then plop from our desks or sofas and binge watch Netflix, we are made to move, we are made to run, we are made to lift things and carry things. I think if we all paid a little more attention to these three very simple, very basic tools, but really be intentional about spending time on each of those pillars of health. I think the landscape would look much, much different.

Bisi Williams  22:09

Kind of nice. I mean, if I was getting my exercise, I would take a stroll to the grocery store, stay in the produce aisle, get fresh vegetables, come home and then have a great night's sleep. It sounds so simple and I'm not making light of it. That's super duper important. Can you just tell us a little bit about how your app works? I mean, take it through the life of a prepubescent woman and her life's journey, does your app cover that full spectrum of a young woman's life? 

Sabina Gal  22:40

Absolutely. So right now, we're still actually in private beta and we have a few 100 people who have been testing the app and giving us amazing feedback. Our plan from the beginning was to launch a very basic version of the app and then get actual input and feedback from real women. And they have helped us tremendously to continue to iterate and build an app with more features. And currently, the way kahla works is that you fill in a very simple questionnaire where we ask you about your symptoms, and your conditions and the symptoms that you choose then become your areas of focus or goals or things to track. And then you have a daily journal that is super easy to fill, it takes only a minute or 30 seconds. Every morning, you do that journal where we ask you about those symptoms. And so let's say that you are tracking maybe fatigue and food cravings, sleep issues and bloating and everyday we would ask you about those four symptoms and you can easily choose from whether you've experienced that symptom that day or you haven't. And then we also ask you a couple of questions related to your lifestyle factors. How was your sleep? How was your stress? Did you get to move your body? Did you hydrate? Are you menstruating, and so on. And then we put all of those together. Every single week and every single month, we show you correlations between those factors and those symptoms. And we're now adding a lot more things that you can track with our app. You can even track stuff like medication, travel, different food groups, let's say you want to see whether dairy affects you or it flares up your symptoms. You can track different food groups, and anything and everything you could possibly think of that could have of course an impact on health symptoms. And then there's an extra layer to our app, which is actually something that I'm very excited about, which is that we want to be able to give women the option to connect with whatever external biomarkers that could be relevant to their health. And that can be blood tests, that can be specialty testing, that can be different sensors and wearables. And because metabolic health is such a huge issue for a lot of women, we have decided to make that our initial focus. And so the first external biomarker integrated with the kahla app is a continuous glucose monitor. So not only women have this tracking app that allows them to track symptoms and lifestyle factors on a daily basis, but they can also wear a continuous glucose monitor, which is a very small device that you attach on the top of your arm that measures your blood sugar continuously in real time 24/7. And that data gets integrated with our app. And for everything that you eat, we give you a score based on your blood sugar response. And we show you how the blood sugar element integrates with all of the other symptoms and factors that you're tracking.

Bisi Williams  25:35

I have a question for you, so when you have a device that's monitoring your glucose, is this when you've been diagnosed with something or is this when you're still trying to figure out what symptoms? Are there, I hate to use this word, but is it an illness or chronic diseases that correlate with some of this?

Sabina Gal  26:04

This is a great question. So those continuous glucose monitors, in short they're called CGM, were initially designed for people with diabetes for them to track their blood sugar. However, in the past five years or so they have become really popular with the general public because they have actually been discovered to be a great tool for monitoring your blood sugar. In terms of preventing future disease or future diabetes, there have been studies that show that continuous glucose monitors are actually better at picking up very early pre diabetes. And they do it much better than let's say, a yearly fasting glucose that you do through a blood draw and your doctors because with a meter CGM, you are actually able to monitor your blood sugar again, in real time content on a continuous basis. And not only do you see what your baseline glucose levels are, but you also get to see really interesting data such as what is your response to different meals? Can you tolerate certain carbohydrates? What are certain foods doing to your blood sugar? How is your blood sugar affected by stress? Because cortisol is known to raise blood sugar. How is your blood sugar affected by our menstrual cycle? Because women are much more insulin resistant in the second half of their menstrual cycle. And so there are a number of really interesting data points that you can collect with a CGM, and you absolutely do not have to have a disease. I will say, however, that a lot of women struggle with something called PCOS, which is polycystic ovary syndrome. And PCOS in the US is the leading cause for infertility in women. What a lot of women don't know is that PCOS is not just a hormonal condition, it's also a metabolic condition because at least 70% of the women who have PCOS are also insulin resistant. And the two are very closely correlated. So for women with a condition such as PCOS, monitoring their blood sugar is actually essential. And we also have currently in kahla, we have a lot of pregnant women who are monitoring their blood sugar because there is a condition called gestational diabetes and that is diabetes that you can develop while you're pregnant. And women who do develop gestational diabetes during pregnancy are again, they have a two fold increased risk for developing type two diabetes when they are not pregnant.

Bisi Williams  28:32

This is fascinating. So what you're doing, and I think this is kind of a breakthrough, is that if you're monitoring now in a preventative fashion, what we eat, how we move right now, you're kind of using this data as a way to prevent a chronic disease from happening. At what point can we stop monitoring, or is this something that needs to be done continuously, do you imagine?

Sabina Gal  29:05

So with the CGM, I actually think that literally every person in this world could benefit from trying it at least one month of blood sugar monitoring because you can learn so much and then you can take those learnings and really be able to tap into your body a bit more and be more aware of okay, so when I eat this food, and before I had no idea, I would have oatmeal and two hours later I would feel fatigue or have an energy crash or feel like I need to eat again. And I had no idea why that was happening. Now because I've tracked with a continuous glucose monitor I know that what's actually happening is that my blood sugar is spiking to a very high level and then it's dropping very quickly, which is causing this sort of fatigue and energy crash to happen. And now I can associate a feeling or a sensation or a symptom to the actual day either, because I have tracked and I know that that is what's happening. If you are someone who has a certain condition, or has a certain genetic predisposition, then you could most definitely track on a more continuous basis and track every month or track every three months, or at least assess once a year to kind of see whether things are changing or improving or which direction they're going in. And it's the same as your bloodwork, you would do your annual blood work and not just do it and put the results in somewhere and never look at them you would assess and see. Okay, how are things changing? How are things? How are things progressing from year to year to year, because it's the only way to actually tell whether there is something that might not be going in the direction that you want it to go.

Bisi Williams  30:56

Sabina this has been fascinating because all of this is available today. And I can see here where kahla is going to be so valuable not only for today, but for the future as women can actually understand themselves in relation to their needs. That this is really a beautiful, personalized app and a way of understanding our bodies and how we use them and what they need. I'm excited for you. Can you just tell me in your final words, when you think about 2049 and 30 years from now, what do you think is the best thing that we can learn today that will help us tomorrow?

Sabina Gal  31:39

The first thing that we can learn today that can help us tomorrow is that everything that we do, every little action that we take on a daily basis from the way we sleep, the way we move, the way we eat is actually data. Data that we can choose to inform how our health is going to evolve over time and whether we're going to prevent disease and live long, healthy lives or whether we're going to have to unfortunately bear the consequences of conditions and symptoms that are going to negatively impact the quality and longevity of our lives. 

Bisi Williams  32:18

Sabina Gal, amazing. Thank you for joining us today on Health2049 and for sharing your wonderful views.

Sabina Gal  32:24

Thank you so much for having me.

Bisi Williams  32:28

That's our show for today. That was Sabina Gal sharing her vision for women's health in the year 2049. Thank you for listening.

Chandra Ghose, PhD., Chief Scientific Officer of Emily’s Entourage

How can we navigate the looming threat of antimicrobial resistance (AMR) and shape the future of healthcare by 2049? Dr. Chandra Ghose, Chief Scientific Officer at Emily's Entourage, delves into the complexities of AMR, highlighting the critical need for global collaboration and innovative funding models. Drawing inspiration from the rapid response to the COVID pandemic, Dr. Ghose explores the economic challenges hindering antibiotic development and envisions a future where technology, particularly artificial intelligence, plays a pivotal role in personalized antibiotic solutions. 

Chandra Ghose serves as the Chief Scientific Officer of Emily’s Entourage, a non-profit organization that funds research and drug development for individuals in the final 10% of the cystic fibrosis (CF) community that do not benefit from currently available therapies.

Before joining EE, Chandra founded Bioharmony Therapeutics, an early-stage biotech startup specializing in developing novel antimicrobials to combat drug-resistant bacterial infections. In advance of that, she worked at the Aaron Diamond AIDS Research Center, an affiliate of Rockefeller University, where she focused her research on developing life-saving vaccines. She was a postdoctoral fellow at Harvard Medical School in the Division of Infectious Diseases, Massachusetts General Hospital. 

Chandra holds a PhD in microbiology from New York University School of Medicine and a bachelor’s degree from Saint Louis University in biology and theology. She is a Health Innovators Fellow at the Aspen Institute’s Global Leadership Network, and a Trustee at the Trinity School in New York. An avid volunteer and entrepreneur, Chandra is involved in a number of causes close to her heart, including Beyond Pads, a non-profit she founded that provides menstrual products to children living in shelters. 

Born in Kolkata, India, Chandra now resides in New York City with her husband, daughter, and their pandemic puppy, Jaws. 

Show Notes

• Chandra Ghose shares her scientific background in infectious disease and developing antimicrobials. [03:40]

• A healthcare vision of the future based on research from the UK government. [10:04]

• A multi pronged medical solution to a bleak future prediction. [13:33]

• Why don't we see more development of new antibiotics in the marketplace today? [17:42]

• How can we ensure the development of new, life-saving antibiotics? [22:56]

• Are there new approaches to treating infectious disease that go beyond antibiotics? [25:58]

• Will we get to a point in the future where we don't have human trials for new treatments? [30:33]

• What’s one change that could have the greatest positive impact in our healthcare future? [34:05]

Transcript

Chandra Ghose  00:07

We have the capacity to really rise to the occasion when we are met with these types of challenges. And we saw this with the COVID pandemic, we've never seen a vaccine trial move that fast. We've never seen different countries, companies, governments coming together to supercharge the development of the COVID vaccines. So, I think there are lots of different parts to this complex problem of Amr. It would require a multi pronged approach, it would require everyone to come together and work together to address this issue.

Jason Helgerson  01:58

Today's guests Dr. Chandra Ghosh is the Chief Scientific Officer at Emily's Entourage, a nonprofit organization that fast tracks research for new treatments and a cure for cystic fibrosis. With a PhD in microbiology from New York University School of Medicine, and extensive research experience, including Aaron Diamond's AIDS Research Center, Chandra has dedicated her career to developing life saving vaccines and treatments. Chandra's expertise has earned her recognition and awards from prestigious organizations such as the Infectious Disease Society of America. Passionate about raising awareness of antimicrobial resistance, she volunteers her time with organizations such as the C Diff Foundation and the Pew Charitable Trusts Supermoms Against Superbugs program. In addition to all her work as a scientist, Chandra is also an entrepreneur. Chandra founded Bioharmony Therapeutics, a biotech startup specializing in combating drug resistant bacterial infections. Prepared to be inspired by Dr. Ghose's journey as an entrepreneur, scientist and advocate for a healthier world. I'm Jason Helgerson, and you're listening to Health2049 and it's my pleasure to welcome Dr. Chandra Ghosh to the program. Chandra, welcome.

Chandra Ghose  03:21

Thank you, Jason. Thank you for having me on today.

Jason Helgerson  03:24

Well Chandra it's great to have you here with us today, we always like to start by giving our guests the opportunity to tell our audience a bit more about their interesting background. So tell us a bit more about your journey that got you to where you are today and your career.

Chandra Ghose  03:40

Yeah. So I always start by talking about going way back. I grew up in Calcutta, India and came to the US for college. I guess the seminal moments in my life have in many ways been defined by infectious diseases that I've been exposed to. So for example, growing up in India, we were always warned not to drink tap water, make sure the water is boiled, if it's the monsoon season, don't have ice cream and so on and so forth. So whether it's cholera, typhoid, these are infections that I had, my friends had, my family, but we always recovered, thanks to really good antibiotics. So, from the get go, even when I was younger, I kind of knew the value of antibiotics, the value of vaccines, and I guess that common thread and interest kind of propelled me as I grew up, went to school, college, grad school and then as my career as an entrepreneur, starting Bioharmony Therapeutics and my current position as the Chief Scientific Officer at Emily's Entourage. One really interesting anecdote and maybe this is pretty unique to me and maybe you won't have another guest on your podcast who has actually experienced a plague outbreak. When I was in high school in the 1990s, there was a plague outbreak in India and we lived through that nothing happened, other than we had to wear knee high socks in the middle of Calcutta summers and go to school like that to prevent being bitten by fleas and ticks. So that was kind of how my formative years spent in India. When I came to the US, I did my PhD at NYU. I was exposed to something really interesting, my thesis was on H. pylori, which is, again, a really interesting bacteria, one of the few bacteria that are related to cancer. So, H. pylori is known to be one of the causative agents of gastric cancer. I did my postdoc at MGH, and that was probably the two most important years of my life. I started off by working in a lab that was developing vaccines, worked on cholera, again, very close, I have had cholera in the past. They were working with an institute called the Diarrheal Institute in Dhaka, Bangladesh and that's what I was initially working on for a month or two. And at that point, there was an outbreak of C. diff at MGH and it was really interesting to see how quickly academic labs and the MDs and the nascent biotech at Boston in 2005, kind of jumping in and springing into action to develop vaccines to treat C. diff infections and therapeutics, such as microbiome pills, for example, that just got approved by Seres Therapeutics, they were being spun out of the lab as I was there. So that kind of put a little bit of the entrepreneur's translational bug in me and I came back to New York in 2007 and I joined David Ho's lab at Rockefeller University. David Ho is really well known in the HIV world for developing therapeutics for HIV and initially, that's what I was working on, but very quickly, I started working on developing vaccines for C. diff. So in a way I continued the work I was doing at Mass General Hospital at Aaron Diamond AIDS Research Center here in New York. Following that, I started up Bioharmony Therapeutics. It was a huge leap of faith, I had never done anything like that. And the work there was to develop new antimicrobials to address this global silent pandemic, which is antimicrobial resistant, which kills hundreds of 1000s of people every year. That's what I spent the past eight years of my life doing. And I recently transitioned to my current position at Emily's Entourage, which is an organization like you said, that funds and accelerates research for the final 10% of CF patients who do not benefit from the amazing modulators that Vertex has developed over the past 20 some odd years. So at Emily's Entourage, my job is to look at really interesting, innovative research and find ways to fund it and accelerate it so that these therapeutics can make it to the patients who really need them the most. There's a lot of common things between infectious diseases as well as ultra rare diseases such as the final 10%, which is this roadblock of funding, this roadblock of return on investment and that's kind of been another reason why I joined Emily's Entourage because I feel my training in the infectious disease world where, I'm sure we'll touch on this at some point where it's funding economics is what holds back the development of novel antimicrobials that is so, so needed, and it's a similar sort of situation and for the final 10% of patients who do not benefit from the current modulators. So that's pretty much me in a nutshell. 

Jason Helgerson  09:31

All right. Well, thank you so much for that. And I'm really excited to ask you this next question, because on Health2049, we really have not had that many scientists, people who are on the frontlines of developing new innovative treatments to complex conditions and diseases. And so I think I'm dying to hear how you're going to answer this question, which is a standard question we ask all our guests, which is what does health and healthcare look like in the year 2049?

Chandra Ghose  10:04

This is actually a really easy question for me. So about seven or eight years ago, the UK government spent quite a bit of time and resources to ask this question. It wasn't 2049. But the question was, what does antimicrobial resistance look like in 2050? So I'll read out some numbers to you, which, frankly, are so frightening that as we're on somewhat of the other side of the global COVID pandemic, it is even more scary. So the number that the World Health Organization published, thanks to this O'Neill Report was that by 2050, up to 10 million deaths could occur annually, affecting economies and shifting more people into poverty. That's just one aspect of antimicrobial resistance. So today, as we speak, more than 700,000 deaths per year is attributed to antimicrobial resistance. And by the year 2050, that number is going to be 10 million unless we do something about this today. And this number, again, it sounds crazy and huge, but I can't imagine 10 million deaths per year, especially affecting those who are the most vulnerable. This would affect low and middle income countries, mostly, they are the ones again, who bear the brunt of a lot of these health inequities. EMR could also significantly affect agricultural production, again, affecting economic and food security, again, for those in the low and lower middle income countries. So I think whether you call it 2049, or 2050, what keeps me up at night is I've envisioned this scenario from where I would be in 2050. So in 2050, I'm in my 70s, hopefully, I won't need it, but let's say I have routine surgery. Nowadays you have routine surgery and if you get an infection, you just reach over, call your doctor, and you can get a prescription for pretty widespread antibiotics, but in 2050, that may not be the case, you may be going to the gym and getting Mrsa. You may be shaving your face every day and you can make it and get an infection and die from that. Common procedures, for example, childbirth, a knee replacement, heart valve replacement, I mean, forget, cancer care, or even transplants. So imagine those routine day to day activities or even routine day to day medical interventions, they could become a life or death decision at that point, because we would be at a post antibiotic age. So that is where I see Health2049 being unless we do something about antimicrobial resistance today.

Jason Helgerson  13:10

All right, so tell us what should we do about it today or in the near future in order to prevent, and I'm quite scared about the future state that you just described, if we don't do something, so what do we need to do to ensure that we have the the treatments necessary to prevent those 10 million deaths. 

Chandra Ghose  13:33

So even though I painted a pretty bleak future, what gives me a lot of hope is that we have the capacity to really rise to the occasion when we are met with these types of challenges. And we saw this with the COVID pandemic, like we've never seen a vaccine trial move that fast. We've never seen different countries, companies, the government coming together to supercharge the development of the COVID vaccines where we ended up getting two vaccines with upwards of 96-97% efficacy and while everyone was excited about that, the thought that was running through my head was, do we really need this AMR pandemic to be that severe before we do something about it? So I think there are lots of things that are already in place. There's tons of exciting research happening. We do have a little bit more vaccine hesitancy now post COVID and you can see those in the numbers of small percentages, but it's still there, where the normal childhood vaccinations are decreasing. So at this point, I would say we should think of ways to fund basic science research. We should think of ways to pump up public health. We should put in resources in the CDC so that when the time comes, they can communicate with people and assure people that they do have our backs, they do know what they're doing. So I think there are lots of different parts to this complex problem of AMR and it would require something called a One Health Approach. So it's not just we focus on human health, but there's a whole aspect of the environment playing a major role in development of antimicrobial resistance. So, I think different sectors have to come together to address this issue. The government can play a huge role, and they are trying to do like, at least the US government is trying to do its part, and also to improve the appropriate use of antibiotics, because we've used antibiotics so easily and so much that it's leading to this development of antimicrobials. And also, we have to make sure that we have a stockpile of antibiotics for the cases where the bacteria is so resistant, that you need one or two or even three different combinations of antibiotics to address it. So not just a stockpile for things like anthrax, but stockpile for Mrsa infection, stockpile common bacterial infections, diarrheal infections, and so on. So, it would require a multi pronged approach. It would require everyone to come together and work together to address this issue. So it's complex.

Jason Helgerson  16:45

So I would like to maybe double click into a little bit about this need for a multi prong strategy. I'm just wondering, of those prongs, I hear that the need to begin to really prescribe antibiotics, the ones that exist today, to prescribe differently to not over prescribe. I hear the need for the development of new antibiotics. I also hear the need to stockpile antibiotics that exist, so that they are easily available if there are outbreaks. And so I'm wondering, are any of those strategies more important than others? I mean, I'm particularly interested in this idea around the development of new antibiotics. And obviously, you started a company to do such work. I'm just wondering why we don't see more development of new antibiotics in the marketplace today. 

Chandra Ghose  17:42

The short answer is economics. You can always follow the money and the reason behind it is, back in the 1990s - 1980s, which was kind of known as the golden era of antibiotics, every single pharmaceutical company at that point, was developing some sort of antibiotic. What happened very quickly after that some of the more traditional antibiotics became generic, and some of the more specialized antibiotics were being held for the most serious cases. So from a pharmaceutical company's point of view, and we need pharmaceutical companies to develop these large scale to do the clinical trials that need 10s of 1000s of people to do these trials when you bring a drug to market, if you're telling the pharmaceutical company, thanks so much, you spend a billion dollars to develop this drug but now we won't use it, these will only be used in very rare conditions when those patients really need it. So there is a huge disconnect between how essential these drugs are and then how these drugs are paid for. I'll give you a very easy example, let's say you go to a hospital and you get heart valve surgery, and you get infected with Mrsa in the valves, it's a really horrible infection to get. The first drugs they'll try at the more generic types. If those drugs fail, more and more of those narrow spectrum drugs will be used to treat these infections. And what happens in the meantime, is that patients are getting sicker and sicker. One of the issues Jason, you know better than anyone, is the whole idea of a DRG. You will pay, I'm going to make this up, let's say $5,000 for a heart valve infection and whether you get an infection or not, that is covered within that $5,000. So a pharmacy, the formulary in the hospital sometimes may not even carry those very expensive and by very expensive I mean $20,000 at most, antibiotics that could make the difference between life and death in these patients. So there's a huge economic issue when it comes to incentivizing startups to develop antibiotics. For example, at Bioharmony Therapeutics, we were developing a non-traditional anti microbial, which is a phage license for the treatment of pneumonia for patients who have Acinetobacter, and Acinetobacter is the superbug of superbugs, if you will. It's number one on CDCs list of priority pathogens because there's very few drugs that can treat a multi drug resistant Acinetobacter infection. But what we faced very early on was this issue with funding. VCs were not interested because they'd been burned in the past. Pretty much every well known VC had invested in an antimicrobial company, many of them were able to get those drugs approved, they ended up on WHOs list of essential medicines, but then went bankrupt because they couldn't sell the drugs. So there's a whole group of antimicrobial companies that have gone through that. So VCs are not interested in funding antimicrobials because they know in the end, there is no acquisition by pharmaceutical companies to acquire these startups. Even if you have a company that's publicly traded, let's say they acquire the assets of a smaller startup that are developing antimicrobials, you can see their shares, prices actually fall on the day those announcements are made. So because of this economic issue, more and more antibiotics are not being developed, because it costs the same amount of money, whether developing a cancer drug or an antimicrobial. So that's where we are. And the Pasteur Act that we just touched upon is trying to address that where you're trying to delink economic incentives from the development of these drugs.

Jason Helgerson  22:11

So it sounds like there's a pretty clear market failure, that the traditional market for pharmaceuticals, we need highly specialized drugs to meet the unique needs of individual patients and there doesn't appear to be enough market opportunity there for manufacturers to be willing to invest in the development of these new drugs. And so it sort of screams out for government intervention, screams out for government investment, which it sounds like we've seen legislation introduced to help in that regard, are you optimistic that the government's going to step in here in the not too distant future to help address this market failure and hopefully lead to the development of more life saving drugs in this area?

Chandra Ghose  22:56

The Pasteur Act that we talked about was initially introduced first in, I believe 2020, and then it didn't move, and then it got reintroduced this year. I think more and more, maybe not in the US, but we're seeing a lot of the European governments coming together, coming up with innovative ways of delinking income from development of these antibiotics, coming up with different ways of paying for these antibiotics. So it would be almost the most interesting thing I've heard being proposed is this subscription model. So it's almost like a Netflix model, you pay a certain amount of money per month or per year for a drug, whether you use it or not. So whether you're watching 20 shows a day or one show in a month, you pay a certain amount. And that kind of gives cover to a lot of these companies when it comes to economics so that the linking of economics with the amount of drugs being used would be way forward. And I think there's this perception that, at least initially, at least in 2020, that if the Pasteur Act is passed, it wouldn't be seen as a handout to pharmaceutical companies. I think this is changing a little bit post COVID because we've seen Pfizer kind of jump in with a smaller biotech company to move their COVID vaccine forward. So I am hopeful but then that's just me in general, but I think in the next few years we will have to see something move, some sort of a national action plan that would include bipartisan legislation that addresses these issues.

Jason Helgerson  24:46

Gotcha. So one question I have is, and this may be a very naive as a non scientist question, but it feels to me like antibiotics is an old technology in the sense that we've been using antibiotics to treat illness for decades, and it sounds like for a variety of reasons, we're getting to a point where some of these drugs that have served the global health well, their effectiveness is in serious threat. But are there at all down the line in the future, new approaches to treating infectious disease? Going beyond antibiotics? Is there a new technology, a new approach that people can be optimistic about? Or is it, we're going to be in for a hard, long slog of developing drugs in similar ways to address these very specific superbugs that sit out there in threat. And so I'm just interested to see as you look forward towards 2049, is there any sort of potential for new ideas to come to the fore between now and then?

Chandra Ghose  25:58

One thing that has come out of all of this is this one Health Action Plan, where addressing human health is not going to be enough, we've seen these amazing antibiotics that have been around for 100 years, since Alexander Fleming and his experiment with the discovery of penicillin and this One Health Approach touches on many different aspects. So if you take the human health aspect we have, the traditional small molecule antibiotics, any kind of antibiotic that you've taken till now is a small molecule, but we are now looking at non-traditional approaches. For example, phage license, bacteriophage therapy, these non traditional therapies are also coming to the forefront. It's almost like an all hands on deck approach. You use small molecules, you use antibacterial products from viruses, which are at the tippy top of the food chain and that's the human health part. The other aspect is animal health. So much of the antibiotics that the world uses today is, 80% almost, used in animal health. We are seeing a movement against that, as well. A lot of different countries, for example, India is promising to kind of move away from using that much. I don't know what would happen in the end, because you have to balance the need for food with the judicious use of antimicrobials in animals. But that is an interesting approach as well. So if we can use all these approaches to decrease the speed or the progress of AMR, I think that would give companies and scientists time to come up with even more innovative approaches to address antimicrobial resistance. So, again, if I could reiterate, we need to create robust national level governance, planning, regulatory legal frameworks to allow for these types of approaches to come to the forefront. It's almost like a G 7 or G 20 approach and these things do get discussed at these G 20 kind of meetings to address AMR. So anything to slow the progress of AMR before 2049 would include environmental approaches, animal health approaches, human health approaches, economics and economic incentives, and so on and so forth. So it's not just the science, but it's also kind of understanding the nuances of where antimicrobial resistance does pop up. 

Jason Helgerson  28:50

Gotcha. So it seems like part of the problem here is just, and you know this as well as anyone, the time and cost that it takes to develop a new drug or therapy, that with the need for obviously, the initial research leading to the clinical trials, and eventually to bring a drug are new treatment to the market, that process takes years. I mean, you mentioned what happened during the pandemic for the vaccines, being like a lightspeed compared to what had happened in the past. I hear a lot about the role that technology can play in speeding up the drug development timeline and reducing significantly the costs and whether that technology is artificial intelligence or quantum computing or already what we've achieved is the ability to map the human genome and gather genetic information on large numbers of people. Eventually getting to a point where we don't even have to do human trials for new treatments and this timeline between now and 2049,  how optimistic are you that we'll be able to make some scientific breakthroughs that will basically speed up the drug development so that perhaps it'll reduce the cost of some of this and just make it easier for companies to develop these drugs and bring them to market much more quickly than historically has been the case? 

Chandra Ghose  30:33

Yeah. So what I'm really excited about artificial intelligence, and where that could take us, and machine learning and so on, we've already seen in the anti microbial development where in the science, at least, or in the research space, AI playing a big role in identifying new small molecules that could address a bacteria with X type of resistant mechanism. We've seen companies that are using AI to look at different bacterial cell wall structures to identify which antibiotics could work against those infections. So, in a way by 2049, is it so unrealistic to imagine a personalized approach to antibiotic development? What if you could make, on a desktop, a small PCR machine, or some sort of machine that could make a small molecule that has different nucleotides thrown on that could address the infection you have right at that point. So you're basically getting rid of every single clinical trial at that point and you're developing personalized antimicrobials to treat each and every person who needs it. And because each small molecule would be different, there hopefully wouldn't be an issue with having wide scale resistance to these small molecules. So I'm quite excited to see where this would go, there's already so much happening in this space. But it's still a very early stage. There's a company that spun out from Princeton called Ara Path that's looking at imaging of various different bacteria to develop antimicrobials that could address or that could get through the cell wall of these bacteria by just doing optical imaging at a grand scale. So, I think we'll get to that point where we may not even need traditional clinical trials because one of the roadblocks for these ultra rare infections, these are still rare in the US, but an Acinetobacter multidrug resistant, Acinetobacter pneumonia is still pretty rare in the US, so to expect a clinical trial of, I don't know, 10,000 people is going to take the company 10 to 15 years and that company wouldn't survive. So I think, from the regulatory perspective, we also need the FDA to open up and acknowledge where these clinical trials are. We've seen a lot of personalized clinical trials in the cancer oncology world and in the rare disease world, like N-of-1 trials. Imagine these as N-of-1 trials, but at the grander scale happening every day in every hospital in every ward. 

Jason Helgerson  33:28

Gotcha. Well, a final question for you Chandra and very eager to hear your answer to this, which is, if you could wave a magic wand today and change one thing and with that change would have the greatest positive impact in terms of us reaching the year 2049. Or use the UK of 2050, in a world in which AMR is not only not worse than today, but maybe even the threat is much diminished, by that point, what change would you make?

Chandra Ghose  34:05

So if you asked me to pick one, I would wave a magic wand and come up with some sort of technology that could help us go back 100 years to Alexander Fleming and look at the way he developed penicillin. So a lot of the traditional antibiotics are made by bacteria to kill off other bacteria. I wish we could go back and really dig deep and see whether there was some other technology that could really mind the virus of the human body and see if you look at the top of the food chain, can viruses give us a hint of how to kill bacteria without having resistant pop up at all. So I would go back and be like, Hey, Dr. Fleming, let's look at viruses a little bit more and see what they have to offer because nowadays, if you look at viruses, like CRISPR, gene editing, all of this is coming from pretty simple organism, such as a virus. So if I could go back and look at ways antibiotics were first discovered and made, I would like to come up with an idea that could address this issue without resistance, because 100 years ago, that was the first time we had antibiotics. In Fleming's own words, he basically predicted that within 10 or 20 years his penicillin would become obsolete. And that's literally what happened.

Jason Helgerson  35:42

Well, thank you very much, and we'll have to leave it there but it's been a very exciting episode here on Health2049. And that was Dr. Chandra Ghose's vision for health and healthcare in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.

Laura Kier, VP of Growth at Centaur Labs

How can medical professionals employ AI to enhance their decision-making process? Laura Kier, VP of Growth at Centaur Labs, discusses her role in healthcare data annotation and explains how the DiagnosUs app taps into a vast network of experts to generate quick and accurate data. She shares a story of how a global medical device manufacturer spent a year annotating data that the app was able to annotate in 21 days. She envisions a future with an AI-driven ecosystem that works with professionals to improve patient care.

Laura Kier is a data expert and technology optimist. She serves as VP of Growth at Centaur Labs, a data labeling platform for companies and researchers on the cutting edge of AI and data analytics, with a focus on life sciences, medical data, and scientific research.

In her current role, Laura works across product, customer success and sales teams to build technology for the medical AI ecosystem, reflecting her passion for finding technical, data-driven solutions to improve the lives of people and society.

Previously, Laura worked in product and operations roles in cleantech, creating infrastructure and policy programs to help people reduce their energy consumption and utilities procure cleaner energy sources. She holds a BA and BE in Engineering and Public Policy from Dartmouth College and an MBA from MIT Sloan School of Management.

Show Notes

• Laura Kier shares her background in technology and AI solutions. [03:35]

• How can the wisdom of crowds aggregate data more efficiently? [06:00]

• A vision of a healthcare future using data-driven AI to provide better patient care. [07:14]

• What are potential barriers to AI implementation in healthcare? [11:02]

• How does the medical app DiagnosUs gather data? [12:10]

• An example of how to train an algorithm to predict medical patterns. [17:28]

• What type of customers are leveraging this technology? [19:08]

• What are the challenges to AI deployment? [21:12]

• Why is making data-driven decisions important for healthcare? [25:15]

• What should we be cautious about with this technology? [27:57]

• Will the data annotation requirements of AI plateau? [31:12]

Transcript

Laura Kier  00:09

One company we worked with, a global medical device manufacturer, spent a year annotating data that we annotated in 21 days. Our speed comes from this network of experts that we have leveraged through our app called DiagnosUs. So we have 1000s of medical students and medical professionals on this app that essentially compete to annotate data most correctly. And what that does is we are able to, at the press of a button, contact this wide network and get multiple opinions on every single medical case.

Bisi Williams  00:58

Hi, my name is Bisi Williams, and you're listening to Health2049. Today we're going to talk about healthcare and data annotation. Approximately 30% of the world's data volume is being generated by the healthcare industry. But it's mostly unstructured right now. If you organized it, it could be broadly used in AI to create learning models for better health outcomes. Here's a stat that blows my mind: data scientists spend up to 80% of their time preparing data, that's collecting it, organizing it and then building training models. Imagine if they could repurpose that time to do what they do best, creating and deploying models to produce the best outcomes across the healthcare space. Today's guest is a self-proclaimed data nerd and technology optimist. Laura Kier is an engineer and holds an MBA from MIT. She serves as VP of Growth at Centaur Labs, a data labeling platform for companies and researchers on the cutting edge of AI and data analytics with a focus on life sciences, medical data and scientific research. It is my pleasure to welcome Laura Kier to Health2049. Laura, welcome to the show.

Laura Kier  03:22

Great to be here. Thanks so much for having me.

Bisi Williams  03:24

It's a pleasure. I'm so excited to talk to you today. There's so much that I'm eager to learn. But first, if you could just tell us a bit about your fascinating background.

Laura Kier  03:35

Sure. So my passion throughout my entire career has been in leveraging technology to impact people's lives and critical global challenges. So specifically, I've always been interested in this from a systems perspective, within highly regulated industries, like clean tech and healthcare. It always struck me that the most boring problems were the most painful, and at the same time, the hardest to overcome. So I started my career focusing on this in the context of clean tech. I was working at a company called Energy Hub, which is a subsidiary of Alarm.com and what we were building was technology to help people use less energy in their homes. And I always like to talk about that as well as trying to improve the electric grid, not the cutting edge technology that is wind, solar and wave energy and things that are maybe a little more sexy, but potentially less impactful to the entire electric system. In grad school at MIT, I took the famous computer science course artificial intelligence and during that class, it struck me that the biggest barrier to AI deployment was not computing power or creative AI approaches, but again, all this unsexy stuff. How do you embed AI solutions into your daily lives? And specifically, what we do at Centaur but how do you get enough training data to build AI? At MIT, I met Erik Duhaime who's the CEO of Centaur Labs. He was getting his PhD at MIT's Center for Collective Intelligence. His research focused on the wisdom of crowds, so how multiple opinions tethered together are smarter than any single expert opinion. You can think about it like you go to a town fair and they're asking everyone, how many jellybeans are in the jelly bean box? Or how much does the cow weigh? And what happens is the most accurate prediction is actually the aggregate of every one submission, no single submission.

Bisi Williams  05:58

Is that a fact, is that really true?

Laura Kier  06:00

Yeah, so that's the idea of generally the wisdom of crowds, how you can aggregate opinions in an intelligent way, will always lead to a more accurate result. And he applied it to the healthcare space and his dissertation in regards to skin imaging. So essentially, looking at how, if you aggregate the opinions of let's say, 10 medical students, you're gonna get a more accurate prediction of is there cancer in the skin image or any other type of pathology than any single 10 year board certified dermatologist?

Bisi Williams  06:44

So what you've just done with that, and brilliant analogy in a sentence or two, you've actually explained what AI does, and how it works in very human terms, which I know we'll get to a little bit later in our discussion about how you think about AI. What is your vision for health and wellness in the year 2049?

Laura Kier  07:14

Yeah, so I really love this question. I think, obviously, in my day to day, but I think all of our day to day is we always think about the short term challenges to health care, drug prices, staffing costs, clinical burnout, my husband's a doctor, so clinical burnout is something we talk about a lot. But despite what makes these headlines now, the whole industry is about people, and how we can keep people healthy and well. At Centaur Labs, we envision a healthcare ecosystem that leverages these insights generated by AI at every turn, to provide better patient care. So you can think about it from the beginning, how people manage their health with fitness and nutrition apps, to how a provider is making clinical decisions. There are all these AI decision support tools, which is a lot of what we do, and help a lot of our customers to know how hospital systems or providers can elevate high risk situations. So making sure you can identify stroke faster, that has a real impact on people's lives, to how medications are developed. So thinking about how do we find the right patients for clinical trials? And how do we look through pathology slides to find different indications of cancer? So we see at Centaur Labs, the fact that AI can be deployed in every single decision and turn in the patient journey. Importantly, our vision is very much contingent on the fact that all these use cases really demonstrate how AI analytics are most powerful when they are working with the humans of health care, doctors, patients, providers and not replacing them. I think there's a lot of conversation about doctors being worried that AI is replacing their jobs. But when you think about those examples I just listed, it's all about how AI can supplement and make their lives better. So the foundation of the company was built on the idea that humans working with AI produce the best outcomes across the healthcare space. I like to tell the story of the founding of the name of the company, which comes from Centaur Chess. So, world class chess champion, Garry Kasparov invented it after he was defeated by IBM's Deep Blue and that was the computer chess program and Centaur Chess is a form of chess where players play with the computer chess program and the idea is they can make the best decisions by marrying, processing data and analytical power of a computer with the creativity and ingenuity of humans, and we really see that happening in the same manner in the healthcare space with doctors leveraging AI at the bedside and scientists leveraging AI at the bench.

Bisi Williams  10:21

I love that. And so now my secret's out, too, because when I'm playing chess with my kids on my phone, I actually run a parallel program to make sure that I'm doing it at the same time. So I don't know if that's cheating. But I like to see how to work with those algorithms and try to make the next move. So I love that your vision has the data, the crowdsourcing the AI working in tandem with humans to do this parallel process. And I'm curious, why are you confident that your idea and our vision can be achieved within 30 years?

Laura Kier  11:02

Yeah, so I think the two major barriers to this vision are the development of AI and the adoption of AI. So on the development of AI, that's a lot of what we're focused on at Centaur Labs, what we're trying to do is help our customers organize their data and structure it such that they can develop these models. You referenced earlier, the fact that 80 plus percent of data scientists spend their time on this collection of data, organizing it and then building the training data. We want to help replace that step and get these products to market faster. One company we worked with, a global medical device manufacturer, spent a year annotating data that we annotated in 21 days.

Bisi Williams  12:02

Wait, how did you take a year of data and get it annotated in 21 days? That's amazing.

Laura Kier  12:10

Yeah, so our speed really comes from this network of experts that we have leveraged through our app called DiagnosUs. So we have 1000s of medical students and medical professionals on this app that essentially compete to annotate data most correctly. And what that does is, we are able to at the press of a button, contact this wide network and get multiple opinions on every single medical case. What's also unique about our process is we have a method of measuring performance. So not only are the people on the app doing the annotations, but we are mixing in cases where we know the answer and cases where we don't know the answer and saying, Okay, we now know that this individual is performing very well, we're going to reward this person. And we actually are not rewarding those who are not performing well. Our CEO actually always makes this joke where if you're a doctor, and you're doing annotation, you might be doing it on a Saturday night and drink a glass of wine and your performance goes down and there's no way to know because all we do is just trust what these doctors are saying, but we don't actually have a method for measuring their performance. So that's sort of what we were able to do. And if you want me to go into it, there's a cool kind of analogy to reCAPTCHA actually.

Bisi Williams  14:04

Yeah, tell me more. I mean, I find this fascinating, the gamification, that you've got 1000s of doctors and students in the system. This is the whole guess the weight of the cow analogy.

Laura Kier  14:16

Exactly, so I'll do a quick tangent here. Do you ever get that pop up that says click all of the stop signs to show your data robot?

Bisi Williams  14:33

Yes, can you make that go away?

Laura Kier  14:38

So what they're doing there is actually helping you annotate for self-driving cars. Which is crazy, I'll explain it a little more. By you going and saying, I see a stop sign here, I don't see a stop sign here, you're actually looking at pieces of data and tagging them. And what they are doing as part of that process is they are putting in some pictures where they know it's a stop sign. And they know it's not a stop side and some pictures where they don't. So for the ones that they do, they're deciding whether or not you're a robot. And for the ones that they don't, they are collecting your work. Our process is similar. What we're doing is we're mixing in some images, let's say we're looking at a bunch of skin images and trying to find melanoma. We're mixing in some where we know that there's melanoma or not melanoma. And what happens is, we can basically tell, are you good at detecting melanoma? If so, we're gonna collect your work. If not, we're gonna throw it out.

Bisi Williams  16:11

That's awesome. It's gonna make me think about that. Now, I have to bring my A game every time I sign up for something. But seriously, I think that's fascinating how you use double blinds, you use multiple ways of testing, and that I feel should bring an enormous level of comfort to everyone. I mean, I love my stuff quintupled tested, if you know what I mean. And I think that in these life and death situations, the work that you're doing is really quite remarkable with this annotation and incredibly exciting. I love that you use this gamification and that your researchers are engaged. Now you've got this treasure trove of information. From my perspective, that's a higher order of design. You are curating and cultivating this material to give you best in class for clarity. That's what we want. It's just clarity. So now tell me how that gets translated, you've got great information sets. How do doctors use that? Who's using your technology?

Laura Kier  17:28

Yeah, great question. So I'll walk you through an example of a company we work with. So the company is called Eko, they have digital stethoscopes where they're able to automatically record heart sounds and lung sounds. What they're trying to do is build on top of that, a software layer that's going to help doctors make the decisions while they're working with patients. So better able to detect different pathologies. The software could say, Hey, we detect a heart murmur or we detect a cough, and that would be really helpful for them at the point of care. So what they're doing is they now have a bunch of data and they need to train and create an algorithm. In order to do that, they need examples of what is a heart murmur and what's not a heart murmur. So they'll send us this data, we will funnel it through our system and through our network, get multiple opinions, filter out those opinions that are not performing well and create a single aggregated opinion, then we can send that back to the customer and say, recording A we detected a heart murmur. And now they have these examples where they can train an algorithm that will predict these patterns.

Bisi Williams  18:57

I find that amazing and this is available today. It's just so incredible and so who's using it?

Laura Kier  19:08

What type of customers are leveraging this? A lot of AI companies, so we're working with this company called Eko. We're working with a company called Page that had the first FDA-approved pathology AI algorithm. So they're wonderful. We're working with a company called Volastra that is trying to use pathology slides as well, but to detect cancer. So a lot of these software AI companies. We're also working with a lot of global medical device manufacturers who are trying to layer this software on top of hardware. A lot of them might be just collecting this data through their hardware. My husband's a GI, you can think about someone who has an endoscopy scope, like those tools, the colonoscopy that no one wants to go to. But they're collecting a lot of the data at the point of care. So they want to have this software layer to help them. And then a lot of pharmaceutical insurance companies trying to do the same level of prediction, a lot of researchers as well. So it's really across the healthcare space that people are trying to use AI to make these predictions and support people through their healthcare journey.

Bisi Williams  19:26

I think that's amazing. When I think about all of these different parts of the body, we're very complex beings, obviously. But at what point does a synthesis happen? At what point do you have the whole corpus from the beginning and how do you imagine layering all of those pieces? So who is it that puts it all together or is that the future state?

Laura Kier  21:12

Yeah, I think part of what you're getting at is how many pieces there are to AI deployment, and how hard it is to align all these pieces and get them used by the people in the healthcare space. It is a real challenge. I think, specifically, there are a lot of companies right now. So we have a lot of companies developing AI and we have a lot of companies that are also trying to be like an aggregate AI solution and help with that deployment. So there's a company called DeepSea and they're trying to be a platform where a lot of different AI companies can work with them and they are in charge of getting it into hospital systems. There's a company called Lucem Health and they're a Mayo Clinic spin off. So Mayo Clinic is a large hospital system, but has a lot of community hospitals that are connected to them, so by sort of doing the vetting and integration of the AI such that there's just one platform for these hospitals systems to interact with, that's really helping get these into the day to day flow of healthcare delivery. I would say another large burden to AI deployment or large challenge is the reimbursement. Who's paying for this?

Bisi Williams  22:52

Who is paying for it?

Laura Kier  22:54

That reimbursement model hasn't totally been figured out yet. A lot of hospital systems are looking at reduced medical misdiagnosis. So can they save a lot of money by having these clinical decision support tools and not have as many lawsuits essentially. I also do see that there's a beginning already of billing codes that are going to let these physicians bill for deploying these solutions.

Bisi Williams  23:29

That's fascinating. So could you give an example, either now or in the future case of a billing code for this technology?

Laura Kier  23:41

Well, I think it would just be something like I have used this technology, in this particular case, and I am being reimbursed for it at the point of care. I think there are a few already in the GI space. But still, it's quite nascent and I think there's a long way to go and then thinking even more generally about regulation and how we can keep, yeah, I don't know this might be a little bit deeper into my knowledge.

Bisi Williams  24:13

Keep going, it's great. I think this is fascinating, because, honestly, I think the intersection where you're working at, where it's really difficult, regulation and policy, because we can dream and imagine all of these things and systematically get them. And what I love about what you're doing with your company is the way that you're thinking, you're sort of designing the space first so that it's not, you don't have an alien baby landing somewhere in the universe, so that it's actually connected. So there's wraparound support and there's a connection in terms of how you can use AI to assist with diagnosis and get better care. And I want to know from you,  why is your idea and vision important? How does it make the world a better place?

Laura Kier  24:20

Well, I mean, asking it another way, why is making data driven decisions important for our health care?

Bisi Williams  25:14

That's a good question.

Laura Kier  25:15

We can think about how data is already being leveraged in all these different recommendation engines in our day to day lives, like the TV shows we watch, where we order dinner from, what apartments come up and the StreetEasy app that I'm always using. And nothing's more important than our health. It's so important that we have all the information to make the best decisions possible. A lot of what I think about in our day to day at Centaur Labs is, it's so important because we collect these multiple opinions on each piece of data, we're able to also tell you the confidence level that we have in the assessment. So you can think about it like if someone just looks at a piece of data and says, Yes, this audio recording has a heart murmur. That's it, you have one person who says this audio recording has a heart murmur. But if we got 10 people's opinions, we can say, four out of 10 thought it was a heart murmur, or eight out of 10. And that's really important, because you can think about how that's embedded both into the AI development, like the level of certainty. But you can obviously think about the broader implications of that.

Bisi Williams  26:50

If you think about that, if we're not using data to the full extent possible, what are the consequences with that, in your opinion?

Laura Kier  26:58

Well, I think there are two things. One is that I think there are real people's lives at stake. So there's so much that goes into a medical decision, how do we not leverage all this information and provide the best care? I would also say, there's a democratization of data piece, and how to access that is super important, because if we aren't using all the data possible, if everyone in the world can leverage the different data, then they can also provide better care to their communities.

Bisi Williams  27:41

I think that's a great answer and I know this show is about optimism and possibility, but I have to ask this one good question. What, if anything, should we be cautious about in this space? 

Laura Kier  27:57

Oh, my gosh, what a good question. So a lot of our customers are applying for FDA approval. And what we've seen as they undergo this process is that the verification is different for each of their different applications. So they need to prove that this AI is working and going to be successful, if deployed. And to do so they need to prove that their AI is helping with detection of these diseases, or improving and doesn't have negative effects. But the reality is, a lot of them, each of them have applied with a different verification process. So looking at one company, they're saying, We proved that the AI was better than three board certified doctors, and that means we're better, whereas another company will apply and say, Well, we had two people look at it, and then one person arbitrate and they all have different processes. And I think clarity over what is the process for AI to get this FDA approval, could be really beneficial in streamlining and getting more AI out in the world, but also add clarity and probably produce safer and more impactful products.

Bisi Williams  29:47

I have to agree with you, Laura. It just seems to me when we think about innovation and regulation that somehow if they could be designed in tandem, because the innovators are really fast and they're super liquid. And the regulators are kind of crystals and they're slow. And if you can imagine, in this process if you're using this AI methodology, have multiple opinions on either side, that the regulators could use that it could have the benefit of that, too. So to take some of the angst out of their decision-making. At the same time, the innovators on the other side could do the same thing. I'm just thinking out loud, because they could then move smoothly through this process for something that we desperately need and clearly want. And that I think that co-design could actually expedite that process and take the pain out of the 80 hours of researching, just putting it all together, so that you can actually use the best minds to work on the innovations, the cool things that they love to do to make the world a better place. And my next question is, will the data annotation requirements of AI plateau?

Laura Kier  31:12

That's a great question. And I think it comes up a lot when we talk to investors and potential clients, because a lot of clients come to us say, Okay, we want you to annotate, let's say, 2000 images. After that, we're good. But the problem is, first of all, they realize, okay, I don't just want to know if there's melanoma, I want to know if there is this other type of cancer, then a new tool comes out that is collecting data in a different way. And it looks different and the AI needs to learn how to collect that data differently. Some self driving car analogies are, you can think about how the data from the streets of San Francisco is going to be different than Philadelphia, you're going to need to have diverse datasets in order to create a robust AI bottle. Skin is actually particularly interesting, because a lot of datasets come from these hospital systems where the population doesn't have a diverse skin color. And so we see a lot of challenges that these hospital systems or these AI companies have when they try to deploy their AI in new communities. Because the people that they're serving are different.

Bisi Williams  32:47

You raise an interesting point because we were just talking to some Gen Z folks, when they talk about the future of health and wellness, that diversity, they already just assume it's baked in. So you would realize that by building these models, that it would have the rainbow of skin colors, I guess, with the presentation of melanoma, and that really opens up a whole other thing, which is very cool. So I guess you're right, it's not going to plateau, is it? 

Laura Kier  33:22

Yeah, it's ever changing. I think it's definitely A, the fact that you're going to always want to uncover more from the data you have B, you're going to need to think about how the data is different and the different locations are going to need diversity. And then what's also sort of interesting is, it's really hard to continue to improve a model a lot of times, our customers will think about, okay, I only need 2000 images annotated and then they just don't get to the level of accuracy that they want to get to. So, a lot of times people talk about data being the new oil and it's very much the same in this space.

Bisi Williams  34:19

And I think you raise an interesting component to your world in your work and what you're laying forward is that we have to be continually learning. This is a process that's rather iterative and it's designed to be that. Eventually, I guess the cost of annotating this data, eventually you've got a body of knowledge and you build on that. And then at some point, there's room for the new and novel.

Laura Kier  34:53

Yeah, I think there's a challenge that our clients are still running into is just accessing enough data. I think sometimes we think about the 30 to 40 year vision and we forget that we still use the fax machine. There's so much data that still isn't digitized. I mean, when we're talking about AI development, it's the data annotation bottleneck, and it's also the data access problem. I'm always surprised how little we accomplish in five years and how much we accomplished in 10 years. I think the data digitization still has a way to go, though, obviously, we've made so many improvements. And I think a lot of this what's really exciting to our earlier part of our conversation about the hardware software solutions is that all new hardware solutions are natively capturing and digitizing this data.

Bisi Williams  36:07

Oh, that is music to my ears. I'm always concerned that we're going to be doing all this incredible stuff on an Atari 64. Could we not do those in tandem? I could talk to you about data and information all day long. And this is a subject that's dear to my heart. This has just been fascinating about this world of data annotation. I just can't thank you enough for joining me today on Health2049

Laura Kier  36:40

Thanks so much for having me. This was really fun.

Hanni Stoklosa, MD, MPH, Co-Founder and CMO of HEAL Trafficking

In this thought-provoking episode of Health2049, we have a captivating conversation with Dr. Hanni Stoklosa, Chief Medical Officer of Heal Trafficking. Explore the transformative potential of healthcare in preventing human trafficking and envision a global system that actively responds to and prevents such exploitation. The podcast emphasizes the importance of incentivizing health systems, measuring success and concludes with a vivid portrayal of a compassionate, trauma-informed healthcare experience in 2049. Join the discussion on shaping a brighter, equitable healthcare future through interventions today.

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Hanni Stoklosa, MD, MPH, is co-founder and CMO of HEAL Trafficking, an emergency physician at Brigham and Women's Hospital (BWH) with appointments at Harvard Medical School and the Harvard Humanitarian Initiative.

Dr. Stoklosa is an internationally-recognized expert, advocate, researcher, and speaker on the wellbeing of trafficking survivors in the U.S. and internationally through a public health lens. She has advised the United Nations, International Organization for Migration, U.S. Department of Health and Human Services, U.S. Department of Labor, U.S. Department of State, and the National Academy of Medicine on issues of human trafficking and testified as an expert witness multiple times before the U.S. Congress. Moreover, she has conducted research on trafficking and persons facing the most significant social, economic, and health challenges in a diversity of settings including Australia, China, Egypt, Guatemala, India, Liberia, Nepal, Kazakhstan, the Philippines, South Sudan, Taiwan, and Thailand.

Among other accolades, Dr. Stoklosa has been honored with the U.S. Department of Health and Human Services Office of Women's Health Emerging Leader award, the Harvard Medical School Dean's Faculty Community Service award, has been named as an Aspen Health Innovator and National Academy of Medicine Emerging Leader. Her anti-trafficking work has been featured by CNN, the New York Times, National Public Radio, Fortune, Glamour, Canadian Broadcasting Corporation, STAT News, and Marketplace.

Dr. Stoklosa published the first textbook addressing the public health response to trafficking, "Human Trafficking Is a Public Health Issue, A Paradigm Expansion in the United States."

Show Notes

• Dr. Hanni Stoklosa shares her healthcare background. [03:35]

• Healthcare is a powerful force to end trafficking. [08:43]

• Focusing on and responding to trafficking can create a ripple effect in transforming healthcare. [18:54]

• What is trafficking and how is the healthcare system positioned to address it? [21:08]

• How can we measure the success of training protocols? [26:29]

• Should the definition of the social determinants of health include individuals who are either being trafficked or at risk? [30:52]

• An example of a holistic, trauma-informed system with better care for those being trafficked. [32:33]

Transcript

Jason Helgerson  

I'm Jason Halverson, and you're listening to Health2049.

Dr. Hanni Stoklosa  00:07

It doesn't even have to be officially labeled as a trafficking program, but in health care if we're addressing social determinants of health, we're also in a way preventing trafficking from happening in the first place like that primary prevention piece. So if health care can be the gateway to housing, for example, and housing could have been a vulnerability to trafficking, there you've actually helped prevent the trafficking.

Jason Helgerson  01:42

Today, we have an incredibly distinguished guest joining us Dr. Hanni Stoklosa. She is an internationally recognized expert, advocate, researcher and speaker on the complex issues surrounding human trafficking. Dr. Stoklosa is the Chief Medical Officer and Co-Founder of Heal Trafficking, and an emergency physician at the Brigham and Women's Hospital. Her extensive experience and expertise spans the wellbeing of trafficking survivors in the United States and across the globe, and approaches her work through a public health lens. Her efforts have influenced policy and practice on a global scale, as she has advised renowned organizations including the United Nations, International Organization for Migration, the US Department of Health and Human Services, the US Department of Labor and the National Academy of Medicine. Dr. Stoklosa's invaluable contributions extend beyond her advisory roles. She has testified multiple times before the United States Congress as an expert witness shining a light on the urgent need for action in combating human trafficking. Through these experiences, she has gained a comprehensive understanding of the social, economic and health challenges faced by survivors and marginalized populations. Given her experience and laser-like focus on some of the world's most vulnerable persons, we at Health2049 can't wait to hear her vision for health and health care in the year 2049. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Dr. Hanni Stoklosa to the program, Hanni, welcome.

Dr. Hanni Stoklosa  03:25

Thanks so much for having me, Jason.

Jason Helgerson  03:27

Well, thanks for being here. And first, maybe you could tell our audience a bit more about your very interesting background.

Dr. Hanni Stoklosa  03:35

Thanks so much, Jason. And thanks so much for this opportunity to really speak into with intentionality what the future of health care looks like from my lens. So a little bit about me, I am from rural Pennsylvania, I'm a pastor's kid. And immediately for some folks that may bring to mind certain perceptions. And for me, really, that was about growing up in a space where I saw social justice as front and center. I watched my father, as a pastor, embody what it looks like to really care for our community, outside the walls even of the faith community and really live out his faith and values. So that was during my formative years. I knew growing up that my life was for others and that at each and every step of my path, I would have a calling. I know it sounds weird to say as a kid that's what I would think about but I was looking for, what is that big calling in my life? How can I be prepared to answer that call? And so that frame of reference brought me not surprisingly to medicine and brought me to become a doctor. I had the opportunity when I was in High School to shadow a physician in Guatemala who worked for this really vulnerable population on the Guatemala City dump and saw the scavenging community that got their livelihood from culling through the trash. How this physician could not only treat their illnesses one by one, but also make a greater impact on their health and well being through public health solutions. So early on in health care, I knew that I didn't want to just be the kind of physician that was treating patients one by one, but that was having a macro level impact in the work that I was doing. Then that led me to try to fill my toolbox of skills along the path of becoming a doctor with things like policy making. I spent a year between second and third year of medical school working in DC at a policy think tank. I spent as much time as I could abroad knowing that outside of US walls we have a lot of lessons to learn and wanted to understand what was being done in the health care space and other settings to be able to translate that back to health care here. And really learning from all throughout the community, how they think about change and organizing. So during my medical school years, that led me to work on issues like HIV AIDS and be involved in community activism, including with Act Up. Then fast forward, this is a very abbreviated version, but all of those ingredients led me to choose emergency medicine and really focus during that time on becoming a good doctor. Then at the end of my training, I was graduating from Harvard Medical School's program and I found that I was at this place where, okay, I've trained to become an emergency medicine doctor, I can save lives in all of these ways. I know I want to have a bigger impact on society. What does all of that mean, what is all of that for? At that time, the research on trafficking in health care came out and showed that the majority of people who access health care have some touchpoint with emergency departments, with urgent care centers, with primary care clinics. I knew at that moment as I read this literature that this was my calling. That if I as this Harvard trained emergency physician didn't know anything about trafficking, how many practicing clinicians were out there around the world practicing that didn't have this information, how many health systems didn't have the tools in place and how many folks are being trained currently that will not have this as part of their curriculum. And so I stepped into that big chasm in partnership with our amazing group of co-founders and we created Heal at that point. So Heal Trafficking is now a network that's in 45 countries around the globe. And we're building a movement in health care to respond to human trafficking and making sure that each and every touchpoint with health care that a trafficking victim has leads to healing. So that's a little bit about my background and kind of what led me to trafficking and working on trafficking.

Jason Helgerson  04:30

That's a great background and I think it really helps to give the audience a sense of who you are and how you got to be who you are today and what your influences are, your motivations, which I think sets us up for the next big question which we always start with with our guests which is, in your view, what does health and health care look like in the year 2049?

Dr. Hanni Stoklosa  08:43

Thanks so much for that question, Jason. So to inform how I think about this question, we've already talked about the fact that I think all health systems should have plans in place for trafficking. And I'll get to that, but my perspective is informed by working clinically in an emergency department and I'm in the midst of a slew of shifts. And so I say all that to say, I see all of the reality of what health care currently looks like very much so. It's what I live and breathe every day and I work with medical students. I work with physician assistants and trainees in those specialties and really have the opportunity in the emergency department to be on the front lines and really work collaboratively with many other places in health care because we are that catch all and because we do take a multidisciplinary approach in our work and so I have these kind of like, hats and perspectives as Chief Medical Officer of Heal Trafficking and then also grounded in that kind of clinical experience. Each and every day, I do a lot of reflection and I feel like I'm constantly updating how I think about what health care looks like currently and where we should be going, where we can be going. It's constantly evolving. So I just wanted to share that. This process for me has also involved a lot of unlearning of ways that I had of thinking and updating that based on evidence, based on listening to survivors of trafficking and other forms of violence, listening to colleagues. So to answer your question, Jason, what does health and health care look like in 2049? I believe in a world where all health systems, it doesn't matter whether we're talking about in the US context, whether we're talking about Malawi, or India, or Australia or China, that every health system does have a plan in place not only to respond to trafficking, but to identify trafficking and to help survivors get the resources that they need. I believe that health care is the most powerful force to end trafficking. Trafficking is a crime. It's a crime against people, but if we're only using criminal justice tools we can't arrest or prosecute our way out of trafficking. And who better than health care to respond to trafficking. Health professionals are trusted individuals in society, our health systems do have safety nets, we're thinking actively about social determinants of health. So we need to learn from how we've worked successfully with other forms of interpersonal violence, like domestic violence and child abuse, and expand those to thinking about trafficking and be that safe space to help those who are experiencing trafficking get out of those situations. I think it is possible. I think it takes a lot of political will to make that happen. But we're seeing that every year as I look at the kind of global benchmarks on trafficking, the US State Department puts out this Trafficking in Persons Report, every year I'm seeing more and more countries where there's engagement by the Ministers of Health who used to not be at the table when it came to anti trafficking efforts. They're saying, Hey, this is a health care priority. Every year, we're seeing more and more education and training of health professionals as it relates to trafficking. So those are all really positive indicators to me that we are heading in the right direction. But where we are right now is not enough. Heal just co-published with the World Health Organization a review of all the literature over the last year on trafficking and health care responses. As we looked at where that literature stands, there were significant gaps. Most of the literature and the research on trafficking comes out of the Canadian context and UK and US contexts and we're really not hearing as much as we should and could be from low and middle income countries as it relates to health care's response to trafficking. I have optimism that we can get there and also, we have a long way to go. So that's one piece, of course, I'm going to talk about trafficking. But I think trafficking is an extreme form of violence and how health systems respond to trafficking is really a litmus test and tells us how we're caring for other vulnerable patients, including other survivors of violence. If we can get the trafficking response piece right, we're going to be providing that safety net for other forms of violence. So it's an expansion of that safety net and it also has that ripple effect for so many of our other vulnerable populations. Just to get a little bit more specific about how I think about that, I do a lot of thinking about trauma-informed care and I'm not sure how much any of your other interviewees have talked about trauma informed-care, but just starting with kind of the basics and also just from where I first thought about this, so when we think about trauma, whenever I was first trained as an emergency physician, I thought about trauma as, are we talking about gunshot wounds, are we talking about motor vehicle accidents and really the physical versions of trauma, but what we're really talking about with trauma informed-care is acknowledging that trauma is not just physical, it's emotional and that it impacts everyone in society, some folks more than others. In a healthcare setting, if we're not acknowledging that people are showing up with past traumatizing or bad experiences in their lives and taking a really a universal approach of being a safe space for those who've experienced trauma, which is really all of our patients, then all of the medical stuff, it's not that it's not, but it really may not be as impactful as it possibly could. And we're definitely not engaging with our patients as well as we could if we're not providing trauma-informed care. So there's been this movement in health care on trauma-informed care, which is great, but it needs some expansion. So as I look forward to 2049, I also see this expanded lens of how we provide trauma-informed care. This comes out of again, my lived clinical experience that it's all well and good to say, I need to be there and empathetic and show up for my patients to acknowledge their trauma. And I know in my head that I can provide high quality care that might even be more efficient. But the reality is that we as health professionals are traumatized, too. And sometimes we even traumatize each other. So the full 360 view of trauma-informed care is being trauma-informed towards ourselves and being trauma-informed towards our colleagues. I had this moment with a nurse the other night on a shift where we were doing just that, the patient-facing form of trauma-informed care and really trying to be mindful of where this patient was coming from in terms of their background. The nurse came up to me afterwards and she said, What about my trauma? What about my trauma and I saw her as just burnt out and tired, and also not seen by her fellow colleagues in the emergency department. And that was really a moment where I realized that we really have to think about this as a three legged stool, how are we trauma-informed towards ourselves, towards our patients and then also to each other. And when we have all of those legs of the stool, then the stool doesn't fall. But if one of them is missing, then it will topple over. So that broader context of having health care be this trauma-informed place which takes culture shifting work, is the environment, is the groundwater, is the change in ecosystem that will allow us to take better care of trafficking victims, of the gunshot victim, of the victim of community violence, of child abuse, or of trauma from their cancer, it changes the ecosystem of health care. So as I zoom out even from the trafficking piece and think about what health care can really look like in the future, I think we need to be actively talking about trauma-informed care in this really holistic way that will allow us to take better care, not only of our patients, but of ourselves.

Jason Helgerson  18:02

Yeah, so very interesting. So basically, it's almost like what you're describing is a ripple effect where if by focusing health systems around the world on meeting the needs of trafficked individuals and in order to do that effectively, you need to provide trauma-informed care and create a trauma-informed health system that is you say is responsive not just to patients, but also to providers. By focusing on the traffic population and responding to those needs, then that will create a positive ripple effect of really transforming the operating system of health care in fundamental ways. Is that the right way to describe your vision for the future?

Dr. Hanni Stoklosa  18:54

Yeah, I think that's exactly right. It's both, culture and operations have to go together. There's statements about culture eating policy every time, but the reality is also if a trafficking victim comes to an emergency department, Saturday 2am, you have an excellently trained nurse who identifies that the person is trafficked and offers resources, they have to know what those resources are and can they access them on Saturday at 2am and what is the plan? So these have to go hand in hand. They're not mutually exclusive. But I think by health systems really asking themselves, are we an environment that can care for trafficking victims, you realize instantly that there are these fundamental shifts that need to take place. And don't get me wrong, I've talked about it on the sort of interpersonal level and I think that's a really important component, but also we have to think about how do we change the structures so that as much as possible, the environment allows us to practice that trauma-informed care towards each other.

Jason Helgerson  20:16

So maybe just in terms of trafficking, it might help our audience to wrap their heads around the degree of the problem. I think there's a lot of people out there who, especially in countries like the United States under appreciate how much trafficking actually is happening on a daily basis and the fact that it's not something that's limited to third world countries or something that happens only in urban settings, but maybe give the audience a sense of the degree to how much traffic is actually happening and why do you think the healthcare system is so well positioned to address that?

Dr. Hanni Stoklosa  20:59

Yeah, great question. So I might back up even more and just say what trafficking is, if you think that's helpful?

Jason Helgerson  21:07

That'd be great.

Dr. Hanni Stoklosa  21:08

Okay, great, when most of us think of trafficking, probably the instant image that comes to mind is someone that's locked away in a basement, maybe for a sex trafficking situation. But I'm just gonna start with some fundamentals about what trafficking is and how it's actually much more beyond that and involves so many more experiences of exploitation that what instantly comes to mind. So the way that I encapsulate trafficking is thinking about a person profiting from the labor of another individual. So it's commercial, there's some element of profit for the trafficker that's happening. And that person that's being trafficked is trapped. So from their perspective, they're not able to leave that situation and they may be experiencing being literally physically trapped in a space, but it may be psychological. We know from domestic violence how powerful that psychological coercion is and keeps people in situations that are so awful, but that that trafficker is using all these forms of manipulation and coercion to keep them in that situation. So someone is profiting off the labor of someone else and that person is trapped in that situation. And then another caveat to give to this which is in the UN definition of trafficking and then also in the US definition is that anyone under the age of 18 who's engaged in commercial sex is considered to be trafficked. The reason that age cutoff is really important is that that person might not say that they're being trapped. It's a very inclusive definition, under the age of 18 any commercial sex is considered as trafficking. That's meant to be really protective so those individuals who unfortunately in the past were considered by law to actually be criminals, we're saying, there is no such thing as a child prostitute. So just knowing how expansive that definition is a really helpful starting place. So we know trafficking affects folks of many genders, sexual orientations and demographics, ethnic and racial demographics across the globe. And at the same time those are who come to mind as when you think of the word marginalized, those communities that are undomiciled, folks that are disabled, folks that are coming through foster care systems. All of these folks are highly vulnerable to trafficking because the traffickers are able to exploit these vulnerabilities and provide some basic needs for individuals at the cost of exploiting them. So given all of that, it's not surprising then that we know that lots of trafficking victims have touch points with health care and that we know that trafficking is much more prevalent than what we're even able to count. To give some numbers to it, what we look at is the International Labor Organization's prevalence estimates. We do not have great estimates of prevalence in the United States, so I'm not going to quote those ones because they're not great. But in 2022, the International Labor Organization released the estimates of 50 million people that are worldwide in as they term it, modern day slavery because it encompasses all forms of trafficking on that global level, so 50 million people. And then I mentioned as I was talking about my own journey of coming to this issue and it really being a calling for me, that there was a study that showed that there's touchpoints with health care. Well, we now know that up to 70% of trafficking victims in the United States whether their traffic for labor or sex trafficking have some interface with health care. So what that means is every day, there are trafficking victims that are going through our primary health centers, that are seeing community health workers, that are coming through our hospitals, their emergency departments, OB GYN that are experiencing trafficking, and to me that represents that huge opportunity and responsibility to respond to trafficking.

Jason Helgerson  21:10

Right. So the 50 million number globally, unfortunately, we do not have a good US number. But is that part of the challenge, too, is that it's a hard thing to measure? I mean, I heard you loud and clear up front that one of your goals, Heal's goals is to make sure that all health systems around the world have programs, have protocols or have the right training to be able to respond, identify individuals who are trafficked and hopefully get them out of that traffic situation. But back to the bigger goal is not just to have the training, it's also to try to actually begin to reduce the number of people who are being trafficked. I'm just wondering about the challenge around statistics. How do you measure success in your efforts beyond just the number of health systems that actually have training protocols in place?

Dr. Hanni Stoklosa  26:29

That's the million dollar question, Jason. I love it. So a couple of points there, as we think about estimating it, you're right we're talking about a clandestine crime. So it's difficult to count in that way, but also because many people who are victims of trafficking actually don't know that they're victims of trafficking. They're not coming forward and to say, this is what's happening to me partly because it's relatively new that we're talking I mean it doesn't seem new to me because I'm embedded in this work, but it's only been relatively recently that the government has really stepped up in the last 20 years codifying trafficking laws as a cascade from the UN laws, which is relatively new in the scheme of crimes. So one of the things about trafficking is that victims themselves are not labeling their experience as such. Some of that's because they're not seeing what they're experiencing reflected in media portrayals of trafficking. But some of that's just purely the manipulation of the trafficker, like the trafficker saying, you don't have rights in this country. And because that victim doesn't speak English and all the information is in their native language, that trafficker is telling them all the information in their life and telling them, if you don't do X, Y, or Z, you're gonna get deported. And by the way, you have this debt and that person just feels like it's an awful situation, that victim, but they don't realize that that's actually trafficking and they have rights as a victim. So I think that's another added layer to the estimates and also an important component as we think about health care response. But to your question around measurement and intervention, I absolutely agree that this is beyond identification, that health care's role. The goal is really to help connect them with resources to prevent them from being re-trafficked. So what are the social determinants of health or what are the Maslow's hierarchy of needs? What are those basic things that that person needs, so that they're able to leave that situation and have a better life. And health care is obviously not going to provide all of those things, but they can be that connecting portal to those resources where they exist in communities and therefore be able to prevent re trafficking. And this kind of gets to that ripple effect thing. If we're identifying folks, it doesn't even have to be officially labeled as a trafficking program. But in health care if we're addressing social determinants of health, we're also in a way preventing trafficking from happening in the first place like that primary prevention piece. So if health care can be the gateway to housing, for example, and housing could have been a vulnerability to trafficking there you've actually helped prevent the trafficking. And then as we measure impact. So I'm laughing because there's so many conversations around prevalence and it's not a laughing matter, but it is really complicated. And how do we measure success? It's a really important thing to think about because is this intervention working in the first place and is it working for some people but actually creating harm for other communities? Those are all things that are really important to track not only unlike the community level or city intervention level, let's say, but also keeping an eye on is the prevalence changing? And how confident are we in the prevalence measures? So they're kind of like multi layered ways of measuring that we need to keep an eye on in terms of intermediate outcomes. Some of these like proximal indicators, as well as that kind of final goal, are we actually reducing trafficking from happening in the first place? And how much do prevalence estimates play into that? Does that make sense?

Jason Helgerson  30:32

Yeah, it does make sense, it makes me actually wonder whether or not we need to expand the definition of the social determinants of health to include individuals who are either being trafficked or maybe even individuals at risk of being trafficked, as just another example.

Dr. Hanni Stoklosa  30:52

Yeah, this is something that I think about in relation to incentivizing this work for health systems. Because there's so much conversation around social determinants of health that I see the direct line to other forms of violence and risk for violence. And what are the implications then in terms of reimbursement, because as much as I can say this is my vision and I think this needs to happen in 2049 unless our health systems are also incentivized besides the goodness of their hearts to get involved in trafficking and see the direct links and the ripple effects across their system, including for workforce retention. I don't know if we'll get there. And so I think making that link to social determinants of health is actually critical and strategic.

Jason Helgerson  31:49

All right. So one more question. I could ask you questions all day, but this is a very interesting topic. But one more question for you for this session, maybe you could describe for the audience, if we get to this point where whether it's through trafficking and better care for individuals who are being trafficked, this idea of getting to a health system that's truly trauma-informed, holistically trauma-informed, what would that feel like? What would that experience be like for someone say, going into the emergency room or going into a primary care office? Maybe you can give our audience a sense of, if we actually got there by 2049, what would the patient's experience be like?

Dr. Hanni Stoklosa  32:33

It would be beautiful. It's so funny, because I'm a pragmatist, a pessimist and an optimist and all those things come together as I think of the future state and all that it entails. But I actually go back to a specific patient example where this is a person that comes to mind when I think about this future state. So she had a horrible past growing up and that trauma is probably the reason why she had diabetes type one, but she has come to the emergency department numerous times because of medical issues. In that future state, while she will still probably have the diabetes that's a direct result of the trauma in her past, when she comes to the emergency department, we're not going to traumatize her by asking her to retell any pieces of her past. We're going to knock on the door, before entering the room we're going to ask her when we have to do her ultrasound guided IV, what arm does she think is the one that we should utilize. We'll provide her with pain medication that she needs as part of any painful procedures and any pain she's experiencing. And we're not going to ask her to repeat herself multiple times as to like what's happening today, that we'll ask her once as part of that clinical visit and she'll get the medical care that she needs for her diabetes complications. Then be discharged to a space where ultimately she has housing and she has access to the insulin that she needs. So it's funny because I didn't tell her story in the negative and I guess I could because I know this same person has come to our emergency departments and been traumatized and just left the emergency department because it was so disconcerting and so chaotic and people asked to repeat herself. Even though she was in need for dire medical attention that required intensive care unit level of medical care, she'd rather leave and risk death to herself than stay in our emergency department. So what trauma-informed care does is flips that script, it acknowledges the past trauma and shows up in the ways that she's identified that she can receive care. I don't know if that helps. I have a very specific patient that comes to mind, but that's just one example that comes to mind. 

Jason Helgerson  35:21

Actually, I think that example is fantastic. And I think it really helps our audience wrap their heads around the possibility of what a trauma-informed health system could look like. And hopefully, your vision of it being achieved by 2049 if not achieved earlier actually comes to be. And with that, that was Dr. Hanni Stoklosa's vision for health and health care in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.

Dr. Jill Bennett, Scientia Professor and Australian Research Council Laureate Fellow at the University of New South Wales

How can a “community of care” model be the future of mental health? Dr. Jill Bennett, a Scientia Professor and Australian Research Council Laureate Fellow at the University of New South Wales advocates for demedicalizing mental health by emphasizing cultural and community-based solutions. She shares immersive media projects from her book, “The Big Anxiety: Taking Care of Mental Health in a Time of Crisis” that empower individuals through creative approaches to working with trauma and mental health. Her vision for the future includes an inclusive experience that provides solutions for those marginalized by conventional approaches.

Dr Jill Bennett is Scientia Professor and Australian Research Council Laureate Fellow at the University of New South Wales, Sydney [UNSW].

A specialist in arts-based approaches to trauma, mental health and engagement design, she is Founding Director of The Big Anxiety festival– an award-winning mental health arts festival – and of the Big Anxiety Research Centre [BARC] at UNSW.

Through her Felt Experience & Empathy Lab [fEEL Lab], she also co-designs immersive media and virtual reality tools for communicating and working with lived experiences of mental distress. Through BARC she has advanced trauma-informed, experiential programs, foregrounding the design challenge of creating safe environments for exploring and transforming traumatic experience. Her books include Empathic Vision (Stanford UP, 2005) and most recently,The Big Anxiety: Taking Care of Mental Health in Time of Crisis (Bloomsbury, 2022).

Show Notes

• Dr. Jill Bennett shares her background and an arts-based approach to healing trauma. [03:04]

• What is the award-winning mental health arts festival, The Big Anxiety? [04:50]

• Dr. Bennett discusses her book, "The Big Anxiety: Taking Care of Mental Health in a Time of Crisis," and how the First Nations approach to health is culturally connected. [06:56]

• What happens if we stop diagnosing mental health through symptoms and instead look at a person’s experience? [08:58]

• The Edge of the Present is the world's first virtual reality suicide prevention. [12:50]

• Why demedicalize mental health treatments? [18:04]

• Peer-led mental health trauma support outside of the traditional medical model can empower people to flourish. [20:21]

• How is it beneficial not to impose diagnostic criteria or to label people in any way? [24:20]

• Are there downsides to demedicalizing mental health? [29:15]

• Why should we change the way we think about time? [33:25]

Transcript

Bisi Williams  00:04

I'm Bisi Williams, you're listening to Health2049.

Dr. Jill Bennett  00:08

It's not the lead facilitator and a few on-call counselors or clin psychs who intervene when things get tough. The idea is that the community is sort of skilled up to take responsibility and to hold the space. So we can create this community of care as we sometimes call it where people are in a position to support others.

Bisi Williams  01:39

Hi, I'm Bisi Williams and you're listening to Health2049. Today we'll explore the question, could the future of mental health be demedicalized? My guest today works mainly with trauma survivors, First Nations people and those whose needs have not been met by existing services. Dr. Jill Bennett is Scientia Professor and Australian Research Council Laureate Fellow at the University of New South Wales in Sydney, Australia. She's a specialist and arts-based approaches to trauma, mental health and engagement design. She's founding director of an award-winning mental health arts festival, The Big Anxiety and of The Big Anxiety Research Center also at UNSW. Through her felt experience and empathy lab, she also co-designs immersive media and virtual reality tools for communicating and working with lived experiences of mental distress. It is my pleasure to welcome Dr. Jill Bennett to Health2049. Jill, welcome to the show.

Dr. Jill Bennett  02:54

Thanks, Bisi, good to be here.

Bisi Williams  02:56

I'm so delighted to have you. So first of all, could you tell us a little bit about your fascinating background? 

Dr. Jill Bennett  03:04

Yeah, well, as you say, I have a background in trauma and arts-based approaches. And over the years, I've developed what we always refer to as a bottom up approach to trauma. And we do that through public engagement of all kinds. We work with communities, we work through our festival, which is carefully curated and unlike a lot of festivals, and then they travel around. It’s very much about responding to community needs. Often we do work with leading artists and designers and interdisciplinary teams to sort of iteratively test out ideas and programs but always really driven through communities and lived experience. I think that's really the innovation that we're pushing thinking about what can a cultural approach that comes from people really do

Bisi Williams  04:16

What I love about your festival and how you describe it, is that the iterative approach and keeping it consistent. I suppose when dealing with anxiety and mental health and so on that the need for constant but surprise and delight is always interesting and even though it's a fun festival, it's actually built on research. So you don't really go out on a crazy limb, you do research when you decide what you're going to do,

Dr. Jill Bennett  04:50

Yeah, absolutely and I think you're right and if you talk about an arts mental health festival people think it's this cheery kind of stuff that is just improving people's mood in this kind of superficial way. Or they think about representing trauma in ways that are quite scary and distressing. And ours is neither of those, it's really working with people with lived experiences to fill a gap. So you mentioned that I work principally with people who say they haven't been well served by existing services, they don't access them, they've had bad experiences, they're just not there. And they're not abundant enough. So we typically will go to communities, research people's needs, and think about what we can co-create together that might meet those needs. And it could be a technologically-based virtual reality experience, or a series of programs that are enjoyable and awesome. But usually we've put quite a lot of research into that, so that we think very carefully about what the mechanisms are, we work in a trauma-informed way, always thinking about how to build safety and trust and agency, and really make collaboration work so it's not like a treatment, it's something we do with people rather than to people.

Bisi Williams  06:38

That's a very important fact, Dr. Bennett, I love that idea. I also want to talk a bit about your new book, “The Big Anxiety: Taking Care of Mental Health in a Time of Crisis.” Tell us about your book.

Dr. Jill Bennett  06:56

Okay, so that brings together discussions of a number of the projects that we've been running and developing through The Big Anxiety Festival. So for example, there are contributions by First Nations practitioners who are absolutely at the center of our program. And the reason for that is that in Australia, we're very lucky to have First Nations cultural tradition that makes no separation between mental health, health and general well-being and the arts and culture. So in order to be well, communities have to be functioning, people need to be connected and feel the safety of community. I think looking to those models is really inspiring for those of us who are caught up in a medical model, that sometimes delivers good things, but generally, it kind of abstracts us from community looks at individual kind of disorders and symptoms, and all well and good if we have a treatment that makes us better. But very often we don't, and those feelings of alienation and disconnection, just continue and cycles of trauma continue. So we work on the basis that we really need to reintegrate people into communities, and that the way we approach health has to be culturally connected.

Bisi Williams  08:38

That's amazing. That idea of baking wellness and health, culturally connected, is so inspiring. I'd love for you to explain your vision for what health and wellness will look like in the year 2049.

Dr. Jill Bennett  08:58

I think, first of all, mental health will be something that exists apart from our medical model. So at the moment, it's kind of an offshoot of the health medical system. What we need to do, I think, is to really build a cultural vision and cultural approaches to mental health and well-being. I think this is a conclusion that the medical sector itself is reaching. The WHO says something like 80% of people worldwide who are deemed to be in need of mental health care aren't able to access the support they need. So to me what that says is not just that we need to pull people into existing supports that they're fine as far as they go. But there's a huge issue of engagement and disengagement. So we need to be starting from a different place, we need to be going out and connecting with people in communities, and looking at first of all the psychosocial determinants of trauma, so called mental health disorders. So if we do that we're committing to understanding mental health within an ecology on the ground. And so any intervention has to take account of all factors. It has to be situated, it has to be community-based. We've been having some success with that already working in communities where we sort of cut through asking people what's wrong with them, and we're looking at what happened to people, and how we can empower them to make change. So in that model, we may take insights, obviously, from psychotherapy and research into trauma-informed practice. But we cut through the need to diagnose people and identify symptoms, because we're looking at experience. I think this is where the arts and culture come in, because you have actually a much richer language for describing embodied experience and emotional experience, and all of those sort of existential experiences of alienation that are, in fact, the symptoms of trauma and depression. But if we work with those feelings, and work on shifting them, understanding those feelings, and working collaboratively to change them, I think we can use all sorts of resources and tools that haven't yet been imagined within the health sector. And crucially, we can think about how we embed them at all levels. So if people are not living there, suburb, town, house, apartment, bedroom, or street, we can work from where people are, and what's going on there and redesign all of the mechanisms for delivery. And I think that we'll have solutions that don't look at all like treatments, in fact, the ones that we have today, deliver through clinical service providers.

Bisi Williams  12:38

I think that's amazing. And I would love for you to paint a picture of what that could look like. I mean, you've done some work with VR and when you say you bring it to us, tell us what that would look like.

Dr. Jill Bennett  12:50

Absolutely, so and you asked me a question about the book as well, and I mentioned one dimension. But of course, we discuss a lot of these projects in the book. So one of the projects we discuss is called Edge of the Present, which is, as far as we know, the world's first VR suicide prevention. And that, as with all our projects came a bottom up through working with, in this case, young men who were survivors of repeated suicide attempts. And what happened in those workshops, we arrived at the idea of working with technology, because young men were making it clear, they didn't particularly want to sit around and talk about feelings. They weren't signing up for these kinds of CBT programs where it requires a whole lot of cognitive discipline and commitment. So we thought, well, let's think about designing something that people actually want to do. But that doesn't mean simplifying at all. We actually then in the workshops, introduced people to a whole lot of research around the mental imagery of suicide, what does what does it feel like to be suicidal? What is actually in your mind? We did a lot of work on data that suggests that there are problems making affective and emotional connections when we're suicidal or severely depressed. So in memory, it's hard to think of things that happened with any kind of emotional intensity or passion and consequently, it's hard to imagine ourselves into the future with any sort of enthusiasm or feeling or passion. So it tends to be this really flat affect. So we knew that one of the things we wanted to do was to create an intensity of experience so that something could be felt. The other thing was the title of that project, Edge of the Present, came from one of the men in the workshops, who said, the feeling is like being at the edge of the present where you just can't move forward, you can't see any future. So the other thing we were working on was how do we invent the future, the next 5 or 10 minutes, just by taking small steps. So we wanted to encourage, doing sort of small actions, but receiving some reward for it. So what we ended up creating, people can see this on online in a video, is a piece that is an roughly 8-minute experience, where you put on a headset, you're in a very plain room, nothing much there, door, window and a table, you initially see a facsimile of that room. But as you move around it, the room transforms, say, open the door, or the window, and massive transformations happen to you in a rainforest, you're on a beach, you're on a mountaintop, and it's just relentlessly gorgeous, then what we found was everybody's mood improves. And we also sort of measured people on the hopelessness scale to see if people became more hopeful. And they did, especially if they were coming from a really low baseline. And the point of this is not just to make people feel good, but it's a series of small actions, big reward. So you're actually making this happen. And that's quite an interesting project. Because although we tend not to focus on the short term measures, because they often don't mean very much in themselves, but this is really an exemplary project to me, because it opens up the potential for having this kind of intervention, absolutely anywhere, in your bedroom, in the workplace, on a building site, anywhere, what if we could fill social spaces with these kinds of activities that cumulatively enable people to take action, and to actually shift the way they're feeling.

Bisi Williams  12:51

I think that's really fantastic. When you talk about in your vision, that mental health will be largely demedicalized and you start to meet people where they are, and you use art, and wonder and community and co-creation, to start to reimagine your future, I know why you're confident that your idea and vision can be achieved in 30 years, but can you sort of explain to us how we're going to transform?

Dr. Jill Bennett  18:04

I do think we need a paradigm shift. So I started off probably more tentatively, trying to build partnerships, and everything's always about partnerships, what we need is a really integrated process. But I also think partnerships can tie you up, if you partner with a health partner, and you have to go through a whole series of approvals and trials and measure yourself by the standards of what works in health, you can end up in the same place and not get very far. So my vision is very firmly that we have to build this cultural approach outside of health. And by that I don't mean that we are in any sense antagonistic to people doing fantastic work in health. I think we can always have partnerships at every level, but I think this idea of growing things from the ground up, has to really kind of stand on its own. And there's always going to be lots of transactions and everything's going to be interdisciplinary. We will borrow what works from anywhere and if a neuroscientist wants to collaborate, that's what we do. We have lots of these kinds of collaborations. But actually in the festival, we evolve this tagline that is people plus art plus science.

Bisi Williams  19:39

Which I think is really quite marvelous and really quite striking. And what I love is working adjacent to all the other institutions but recreating and actually making space for all folks who are interested in healing from within and from without, and with the community that they can all play a role. And I love what you're saying about this co-creation and world building. And from your perspective, and from the work that you do, can you just share why your idea and the work that you do is important, and I know it is. Then can you tell us how it makes the world a better place?

Dr. Jill Bennett  20:21

I mentioned the project that we were doing last week, we've been working with this community in Queensland all year, coming back and doing workshops, and then making media and film with them in between times and what's happened there is, people are really saying that they're finding a way to go back to the trauma, to work with deep feelings that are deeply distressing that they haven't really been able to shift. And so fundamentally, it's opening up a safe space to do that, and having some skills around it. But again, it's not clinician-led, it's peer-led, but saying that it's by expert peers who've been working in trauma support for a long time. And it's using creative resources to visualize internal processes, but also to visualize shifts. But it's really about building that empowerment. And when I see that happen, it's especially in this case, I realized that this is not just as a sort of one off creative imagining, but it's really a process that can be generalized, because we're working on intergenerational trauma, which is something that actually the medical model doesn't have much to say about because it's very hard to identify and understand the mechanisms by which trauma is inherited, you can't sort of see that under a microscope. But we do know that First Nations communities and in Australia, along with many others around the world understand it, because we see that trauma revisited, we see how hard it is for traumatized parents to parent in a way that ensures children don't inherit these high levels of anxiety, alienation, disaffection, and trauma. And so the solution is to build the capacity of the community to have insight into what's happening and to support them to be able to deliver effective levels of support and to actually be able to sort of self validate, I think that's really important, often we carry levels of shame and the feeling that we are ineffective and can't overcome the distress that we're feeling but but all of us can if we are supported to do that, and enabled to have that kind of agency over our own lives and the lives of our families. So watching that happen is really empowering and you realize in seeing it, that actually, the processes are known and they're simpler than we imagined. But they are processes that aren't allowed to flourish in systems that simply pathologize trauma or the effects of trauma.

Bisi Williams  24:01

I'm going to ask you a bit more about pathologizing, but I also want to ask you about, you have a theory, which I support, about the doing rather than being done to. Can you talk about that in your work and in the communities?

Dr. Jill Bennett  24:20

Yeah, I think we're actually very open, as I say bottom up always and so we never know what a project is going to be until it emerges. But we do work with some irreducible trauma-informed principles, and those would be ones that are widely recognized as trauma-informed but we prioritize building safety, trust and trust means, often removing hierarchies and being non-judgmental, so listening rather than labeling. So at that point, it's very useful to us not to impose diagnostic criteria or to label people in any way, to just work with the experience that people bring. Then to promote choice and collaboration. So those will be the other other pieces and promoting choice means really enabling people's agency and opportunities, and then working together collaboratively. So everyone is doing with rather than, you have some facilitators or experts doing, too. And I think the point there is that in the event we ran, last week, there was actually a wonderful First Nations facilitator host Marianne Waltke, who's part of our center, and she's actually a trained nurse and a midwife and has worked for many decades on sort of frontline trauma support. So she was, in a sense, the lead facilitator, but she is at pains to say no, there was no leader and that process works because what we build as a community of care where it's not the lead facilitator and a few on call counselors or clin psychs who intervene when things get tough, the idea is that the community are all able and that they're sort of skilled up to take responsibility and to hold the space. So, not everybody needs to be doing that at the same time. You can take time out, it might not be the right day for someone to really listen and absorb the experience of another. But that doesn't matter because within a given group, different people can take up that role. I think that happens when the community of care is working. I always remember, we did a workshop a few months ago in that community and there was one woman who, in mental health terms, is really significantly ill, lots of diagnoses, but very disaffected. And she came up to me at the end, and she was very pleased because the event had gone well for her. And she said, Oh, you know when you said there's a counselor in the room who's on call, if anybody wants to talk, I made a note to avoid that person. I love that because, she said it as a joke, her whole thing had been, ah, I'm so over professionals. But the serious side of that, and what was really pleasing, if you get that kind of comment in a feedback survey, is that what it's actually saying is we didn't need to go to a professional because we the community, were functioning, I felt safe, it was working, we can create this community of care, as we sometimes call it, where people are in a position to to support others.

Bisi Williams  28:40

I love the term community of care and that it's horizontal, because ultimately you want everyone to be in community. This is really important and community in an authentic fashion. So given all of this positive research, feedback, actual people thriving and building communities, do you imagine that there could be any downsides to demedicalizing mental health?

Dr. Jill Bennett  29:15

No, because there is such a big gap so we have to put something in the gap. We have to be operating across community spaces. Now, I suppose the knowledge is held tightly by the medical community and they might say, well, there's all sorts of risk. In one of the recent events we did in Melbourne someone came and joined one of our long tables, which was a discussion on suicide and trauma. She told a story where she'd been discharged from hospital and she had gone into a space that had a sign up saying community mental health center, all welcome. She went in and had a five minute screening and was told she was too high risk, and so they wouldn't accept her and that was absolutely devastating. This is the way this kind of triage works, it's too high risk so there's nothing, just wait until you're an emergency case, and then you're admitted to the emergency department. So what we're thinking is, we need to step in where there isn't care. And if we do that, in a respectful, trauma-informed way, there isn't much that can go wrong. We do a lot of work in these workshops around triggering and projection, people have a propensity to be triggered, and to feel marginalized and left out and let down and everything else. This is not just people who are diagnosed with mental illness, it's every one. So we always place an emphasis on reflective practice and catching those feelings early. At the point at which stuff's coming up, you're a little uncomfortable, you want to get out of here, of course, we have a lot of bodywork, massage stuff going on, so you can go out, you can process, you can come back. But we always say don't rush off, we do have a principle actually don't rush home, we say just touch base before you do that. Because if you're triggered, the thing we can do is to support the processing of that in a reflective way. Then you're triggered in a good way, because you learn to regulate and to manage that triggering and that's something we require of all the practitioners and facilitators as well. It's all in it's, there's no difference here. You're not there managing a bunch of patients with thinking about how we interact and what creates a safe environment all the time. So that would be the danger that people are triggered. But it's not a danger if we build into practices an awareness and learning how to be with others. And I think that's not rocket science. It's a long project and it requires listening and attentiveness and listening to ourselves. But it's something we can build into everyday practices, it's not specialist knowledge. So that will be something that I think we can all access.

Bisi Williams  33:05

I just want to touch on one other thing that I've just learned from you today, that time is very important. Designing the time. What is it about our time now, how would you design time differently from a societal perspective?

Dr. Jill Bennett  33:25

Yeah, we need more space and time, and I have been caught up previously in those cycles where someone gives you a grant or something to do something, and then you have to evaluate it, as soon as it's done, do a survey, is everybody feeling better? And maybe they are, often they are, but really some of my best results are two weeks after we've done the survey, someone calls up and says, big things are happening. I've cleaned the house for the first time in two years. This is why we have some of these projects where we work with a small town, small community and go back and see what's happening. Because I think we get caught up in what we think is evidence-based when we really need to have a different lens on what change is and so we need this bigger picture, actually, we need to look at what's happening with people in communities and how it can be sustainable. I think that is about changing the way we think about time. We also think about what we can deliver in a really short timeframe. So especially with our VR tools, we think about what can be delivered in 15 minutes so that people can access it when they have a break at work. People don't have to go far, they don't have to prep. They don't have to give up a lot of time, that's not intrusive, but if we can put this in the right place, give people access, and then they can come back for more and access other resources. That's really important as well. It's not like signing up for a big lengthy, expensive time-consuming program. If people don't have the time, okay, we'll we'll start with five minutes, we've got something.

Bisi Williams  35:42

Okay, that just warms my heart. I'm sold and I can't wait to participate in this future. I just want to thank you, Dr. Bennett, for sharing your vision for health and wellness in the year 2049.

Jill Bennett  35:59

Well, thanks Bisi and I'm really keen to work with you more to and before that timeframe. Let's start now.

Bisi Williams  36:07

I'm agreeing, I think nothing like the present, so I'm 100% with you on that.

Errol Pierre, Senior Vice President of State Programs at Healthfirst, Inc.

How will healthcare in 2049 be shaped by advancements in technology, access to education and the intersection of health and wealth? In this thought-provoking podcast episode, we have a captivating conversation with Errol Pierre, Senior Vice President of State Programs at Healthfirst. Explore the potential impact of AI, telehealth and local collaborations on the future of healthcare. Delve into Errol's insights on addressing disparities, fortifying social service programs and the crucial role of policy changes today for a healthier and more equitable tomorrow. Join the discussion as we envision a transformative healthcare landscape and consider the question: What interventions can we make today to shape a brighter healthcare future in 2049?

Errol Pierre is the Senior Vice President of State Programs at Healthfirst, Inc, the largest non-profit health plan in New York State, serving 1.7 million members. In this role, he is accountable for growth, profit/loss, sales and retention for the Medicaid, Long-Term Care, and Commercial product portfolios.

A Bronx, New York resident, Errol graduated from Fordham University with a bachelor's degree in Business Administration with a concentration in Finance. He later obtained a master's degree in Health Policy and Financial Management from New York University. In December 2021, Errol completed his doctoral degree focused on Health Equity. Lastly, he is an adjunct professor at New York University, Columbia University, and Baruch College teaching various courses in Healthcare and Business. In his spare time, Errol volunteers for numerous non-profit organizations as a board member of the Arthur Ashe Institute of Urban Health, and a member of the national 100 Black Men's Health & Wellness Committee.

Prior to Healthfirst, Errol spent over 10 years at Empire BlueCross BlueShield, which is the largest for-profit health plan in New York State serving close to 5 million members. Errol's career in health care started at Empire as an intern in 2003. Throughout his tenure, he held various leadership roles in Sales and Strategy, leaving the company as the Chief Operating Officer in 2019.

In 2020, he was acknowledged as one of the Caribbean-American "Power 100" by Carib News and was awarded for "Outstanding Community Service" by the Asclepius Medical Society. In 2018, he was recognized for with the Outstanding & Dedicated Service Award by 100 Black Men and the Home Award by the National Organization for the Advancement of Haitians. Errol is an avid traveler visiting over 35 different countries.

Errol added published author to his long list of accomplishments earlier this year when his book, The Way Up: How to Climb the Corporate Mountain as a Professional of Color (Wiley) became available.

Show Notes

• Errol Pierre shares his background in the healthcare industry. [03:34]

• How can the future of health care potentially be the best of times and the worst of times? [05:37]

• Can AI-assisted diagnostics fill the gap of the healthcare’s workforce shortage? [10:43]

• What are the potential issues around access and health disparities? [14:55]

• How can we create access to new healthcare technologies that bridge inequities in the system? [18:31]

• What will the role of the health insurance company be in 2049? [23:04]

• Will we have a more consolidated healthcare system in the future? [25:43]

• Can a local healthcare solution work for all subpopulations, including caring for the unique needs of transgender individuals? [29:20]

• How can we ensure a brighter health care future? [31:39]

Transcript

Jason Helgerson 

Hi. I'm Jason Helgerson, and you're listening to Health2049.

Errol Pierre  00:08

We have a habit to put money at the symptoms as opposed to the root cause. When we look at the root cause of why certain populations have worse outcomes and other populations, of why medicine is inefficient, there's such a strong correlation between health and wealth. And so where I would put my bets is ensuring that the next generation of Americans that come into this country, they are well educated to be able to get high paying jobs, increase the median income, increase the middle class. They have access to fresh fruits, fresh food, they can exercise, they can take care of themselves, they can build strong families. If we focus on those things, naturally, our health care costs will be lower.

Jason Helgerson  02:10

Prepare to be inspired by today's guest, Errol Pierre, a business executive leadership coach, healthcare strategist, public speaker, Professor and writer. With over 17 years of experience, Errol has dedicated his career to achieving health equity and empowering individuals to reach their full potential. Residing in the Bronx for the past two decades, a county known for its health challenges, Errol believes that health care thrives when it is rooted in local communities. He has made significant contributions to both for profit and nonprofit health plans in New York, while also teaching at Ivy League institutions and captivating audiences as a public speaker worldwide. His dedication to community work has garnered recognition from various nonprofits and business organizations. Currently, Errol serves as the Senior Vice President of state programs at Health First, the largest health plan in New York. Join us as we delve into Errol Pierre's wealth of knowledge and expertise in healthcare leadership and community empowerment. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Errol Pierre to the program. Errol, welcome.

Errol Pierre  03:24

Thank you. Great to hear you, Jason.

Jason Helgerson  03:26

Well, thank you for being our guest today. I'm hoping that maybe you could tell our audience a bit more about your interesting background.

Errol Pierre  03:34

Sure. So I started my career in healthcare accidentally. I ended up interning at a very large for profit health insurance plan, and found out that I was pretty good at solving complex issues. So stayed there for 10 years, changed different departments, product sales, strategy, business development and learned a ton working in the blues, that system before moving to one of the largest nonprofit plans in New York. That's how I came over to start with the implementation of the Affordable Care Act and so that was one of the best learnings ever, because policy was changing so much in Washington and impacting the nation and I had a front seat at those changes back in 2014 when the exchanges launched. So from there, I grew in different responsibilities at the company and now I'm serving as Senior Vice President of State Programs at Health First. You mentioned teaching, I'm teaching health economics at different schools and then also learning from students as well. So that's a little bit about my background. Then during the pandemic, I also wrote a book called "The Way Up" that really dives into what it takes for professionals of color to navigate Corporate America, as being sometimes the only person in the room of color and then also feeling like an other. I interviewed 11 executives of color as part of that process and it's a book, both for people of color that are trying to grow in Corporate America, but also bosses and managers and supervisors that have diverse teams and want to learn more about how to help their employees be successful. 

Jason Helgerson  05:24

Great, all right, so with all our guests, we always start this conversation with the standard question, which is, what does health and healthcare look like in the year 2049?

Errol Pierre  05:37

That's a huge question and I had to think about how to slice and dice it. And I have remnants of a "Tale of Two Cities," the best of times and the worst of times, essentially. And I say best of times, because I feel like by then, technology will be even more amazing than it already is. And so I project that AI and tools around decision making will probably be doing like 75% of our health care decisions in medicine, meaning all the tools that we have, if you were at the starting phase of ChatGPT, but imagine that extrapolated all the way out to 2049 where diagnosis will be done very, very, very quickly. And computers will be right in the thick of things with a physician as they provide care, making decisions. I think hospitals, and the concept of a hospital will fully be at home, we see pilots of it now. But by then we'll absolutely see hospitals at home programs where someone can actually stay in their home, for even surgery, potentially, or stay in these sort of makeshift hotels that are built for surgery. So totally flip hospitals on his head on what we think about what they look like. And obviously, genetic mapping and precision medicine will definitely be in our future where we are now getting a pill that's designed for you, as opposed to generic medicine, which just speaks to amazing medicine, amazing solutions, amazing treatments for many, many Americans, which is amazing. That's the best of times. And then the worst of times, is that it's going to be a greater divide between the haves and the have nots. So all the positive things I just mentioned, which I think are just going to be so amazing for people to treat cancer, and to slow down what diabetes does to the body and hypertension, and being able to treat folks quickly and efficiently without human error or mistakes. And comparative research will be even better, so that treatments will be so good. The problem with that is I'm concerned about who will get access to all of that new technology and all that new health care. So the worst of times is that I think it'll be bleaker for the have-nots. If you think about the government programs, will Medicare be around by then and what will it look like? Will the age level be higher, maybe it'll be 75 years of age. Disparities that we have today, how much more will they exacerbate if we're treating people faster and better, and only a certain group of people are getting access to it versus another group of people. So I do think disparities will exacerbate. And then the part that scares me the most is, we're sitting on physician shortages. Granted, technology can assist with that, but that won't help all the way. But the biggest issue I see is the lack of diversity in the clinician population. So we have physician shortages today. Everyone knows about the nurses shortages today. Those will continue to exacerbate but on top of it will also be the disparities in physicians of color that are going to be serving a population because everyone projects that by 2050, we will be a minority majority country, meaning we will have more minority populations than non minority. This is going to probably be the Hispanic population that's going to be one of the biggest populations in our country. And do we have the workforce to serve them? That's my biggest concern. So best of times, worst of times. Jason, that's that's the way I could say. 

Jason Helgerson  09:28

So there is a lot there. A very comprehensive vision of the future. Maybe just dive into a few aspects of it talking first and foremost about the workforce. The World Health Organization, projecting that by the end of the decade globally, will be 18 million healthcare workers short of what the demand is, and it's spurring a global conversation. I was at a meeting in Rome a few months ago, where it was a global conversation around the fact that we can't hire our way out of this problem, and now we need to automate. And you're clearly optimistic about what technology is going to be able to make possible. And whether it's the hospital and home model you talked about, or the power of AI-assisted diagnostics. Do you see a fundamentally different role for, say, physicians or nurses or sort of direct human to human care? Do you see that more of our care is actually provided, not by humans, but by machines, and is that maybe a way out of that workforce challenge that we already have today, and as you say, could get worse in the future?

Errol Pierre  10:43

Yeah, I do. So if you think about how inefficient our system is today, you feel you have a cough, you book an appointment today, you put in your information into some site where you can book an appointment online. You still show up to the doctor's office, they still ask you for the same information that you just submitted online, you have to fill out all these informations that ask for your name several times on the same piece of paper, the nurse sees you first and the doctor sees you, you get a script and you go to the pharmacy. Even though we're 2023, it's extremely inefficient how we do it, where with AI and technology tools and even advanced telehealth, that diagnosis can happen potentially in your home with all the devices that we can have that can tell if you have a cold or not. And so you don't have to go to the doctor to determine if you have a cold. So I think there's going to be way more tools that are diagnosing that you can do on your own, where what the clinician is doing is just validating what the computer has produced. So I think if we can get the low acuity diagnostic services out of those doctor's offices, that changes the way it is. I also think the way we live will change because we're also out of space in terms of housing. So today, we built these big apartment buildings. We start out with gyms in the basement and maybe there's a dry cleaner. I definitely think apartment buildings of the future for urban areas are going to include clinics. We already have Amazon Go stores where you can go into a store with no one there and leave and pay for a product. I think very similarly, there's going to be tools that can do diagnostics inside of a clinic where you don't need to talk to anybody for the low acuity things. For the higher acuity things I do think caregivers, family members are going to take a much, much bigger role, especially because the senior population is only about 17% of the US population today, that's going to exacerbate because we're keeping people alive longer. So maybe it's going to be say 25%, if not higher, by 2049. And so there's definitely going to be more family members, caregivers taking care of their family, maybe their mother, their father, sister, brother, etc, etc. And so they will now have tools enabled for them to provide care as well. So we already see the early days of CDPAS, which is big in New York, which is consumer directed where you can have a family member take care of you in the home. But think of that on steroids, where now you can diagnose your mother with technology tools to find out what things are happening and the drugs will get delivered to you. And you don't even see a doctor. I mean, some of these decisions, because the computer will be right so often that it'll just bypass the need for a physician. So I think we'll get there. And again, my biggest fear is who gets access to it. It's going to be who has money that it's going to get access to these types of tools. 

Jason Helgerson  10:44

Yeah, so let's get right into that issue around access and health disparities. I think I'm a little more optimistic than you are around it in the sense that I think the unit costs on some of these things, the artificial intelligence tools, for instance, they'll be so low that they'll be inexpensive, that some of these things, the diagnostics you described, some of those things could be really very affordable, very cheap. In fact, at some point in your unit, the marginal costs will be close to zero. My worry is more on what you mentioned previously, the precision medicine, the medications uniquely designed for just you, branded types of things that are under patent that could be very expensive, but maybe talk a little bit more about the kinds of things that won't be as accessible or potentially couldn't be as accessible in your future world. 

Errol Pierre  14:55

Yeah, so the way I think of it is COVID to me, it taught me a lot of lessons. When we had the COVID pandemic, we quickly set up ways for people to get vaccines, we set up a website, so you can book appointments. And what I saw firsthand working at Health First and working at a plan that serves the underserved, more than 1.2 million of our members are enrolled in Medicaid, so they're making less than $18,000 a year, was a website that was built for people who had a desktop, that spoke English and that were mobile and could use transportation to get to their sites to get the vaccines to the point where people that were outside of the city were taking vaccines from the locations that were inside the city. So people in Long Island or other areas outside of New York City were actually being able to book appointments for locations inside the inner city, where the inner city folks could not get access to it. And so to me, when I'm thinking that as as a microcosm of what's going to happen with the expansion of technology. Yes, those diagnostic tools might be cheaper, but I'm thinking about, Okay, what will be the device that has access that provides those services? And will that device be ubiquitous amongst everyone, despite their income? With AI, many of the jobs that low income individuals are working today, these are the cashier clerks, we're already seeing those jobs go away, so with AI, will be much more changes in how the job market operates. What happens to those folks? Where are they getting their income? Where are they living? What will they be doing it because AI is not just going to impact health care, it's going to impact all industries. And so many of the folks that are on Medicaid today, they are doing the labor jobs of keeping the United States working and afloat. But those jobs displace what happens to them whether they get their care. So I think those are the fears that I see. We have to make an intervention today to change the trajectory toward tomorrow. And the last thing I'll say, too, is embedded in all of this AI is already bias, unfortunately, because humans aren't perfect. So we're taking all of these decisions that have been made, 1000s of decisions are made every single day in medicine and these algorithms are taking all these decisions and obviously, some of them are wrought with bias and systemic issues. Those go into the decision maker, so to the degree that we can check those algorithms for bias, I don't know how we do it and offset it. The other thing is the exacerbation of it because the AI is going to be everywhere is the fear of people just missing out on care and the algorithm exacerbating the bias that's already existing in the system.

Jason Helgerson  17:57

So in terms of, let's stick with healthcare delivery and your concerns around exacerbating the inequity in terms of access that could be created by some of the new technologies, what is your prescription for that in terms of what do you think the government or providers or insurance companies could or should do between now and 2049 to help make sure that those inequities are not as bad as you fear they could be? 

Errol Pierre  18:31

Yep, absolutely and if we make changes now, I think 2049 will definitely be much brighter. So things like policy changes that put money to where we need to get to. You know this better than me, our system is fee-for-service, so it drives behaviors that do us a disservice. We have to get off of this fee-for-service chassis as fast as possible. The hope is that in 2049, it is different because if it's not, the behaviors that we get from fee-for-service is more expensive care, more sick care, less preventive care, less focus on primary care, less focus on preventive medicine, that will not change unless we change the way we pay providers and incentivize them. So I think that's the first big thing we have to change. Two is our concept on funding social services. So we talk about social terms of health, we talk about health equity, we're early days of trying to screen everybody, but the problem is, if you screen everyone to ask them their needs, but there's no place for them to get those needs met, we didn't change anything. And so before we start screening folks for food insecurity and for housing issues, we have to fortify those resources to make sure that there are places where they can get food and not just food pantries, because those are sort of nonprofit band aids to help with supplemental food, but actually social programs, so programs like SNAP benefits, has to be totally changed to align with health care. Make SNAP literally a food as medicine program to say, actually want to give people food because that will help them be healthier. Instead of like, Oh, it's a social service program that we want to cut, say actually no, if I can invest in this program, I'll actually keep people healthier. So the food deserts that exist, they totally have to be upended for the purposes of people living a life of equality and basically have better health outcomes. The other piece I'd say, too, is, if we know we're going to be a minority majority country by 2050, based on all the demographic data that's out there from the US Census, we have to staff accordingly for that population. We have to start totally thinking about how we do recruitment. You brought up the fact that we can't hire our way out of it. If you add on top of it cultural competency, it's even worse, the disparities in the clinician population. So we literally have to train people about health in schools. It is not a class on taking care of yourself, it's being healthy. Probably when I went there was a health class. It's something that we train people today like what to eat, what not to eat, exercise to get, how to take care of yourself, that has to be ingrained in people today. So we have to change how we educate folks around that process. But then definitely change the trajectory of how hard it is or easy it is to get into healthcare delivery because we are so far from being able to handle what the population will look like in 2049 unless we make changes today. 

Jason Helgerson  21:50

Right, I agree with you 100%. One of the underlying premises of this show is that 2049 may seem like a long time from now, but the decisions we make today will have a direct impact. One of our previous guests is the Vice Dean at Columbia School of Medicine, and is working on a project to transform the curriculum with the idea that the physicians being trained today will be in the heart of their practice in the year 2049. And so the reality is that the decisions we make today will have direct implications out there in 2049. We have no choice but to start thinking differently about all aspects of the system, particularly as you talk about the need for cultural competence, the need for recruiting and training individuals of color into the industry, into the space, all exceptionally important points. You're a senior executive with a health insurance company, so I'm interested in your thoughts on what the role of the health insurance company will be in 2049? 

Errol Pierre  23:04

Yep, there's a question of what health insurance will look like, because there's a whole transformation of the payer space today. We have a payer in the country that's the biggest owner of physician groups right now. So payers are definitely changing what they look like. And I think that 2049 will see a much more blurred line between payer and provider. It's happening already, but I think we're going to get to a point where if health care is local, the government will probably get to a point where they'll provide money to someone who not only can pay claims, but also can deliver care, just from an efficiency perspective, so much more pay vitor approach with a population health lens where you say, I'm a hospital, I have a group of physicians and I can process claims and I can manage a population of members from a population health perspective, let me take over this population and be responsible for it and provide me the funds to manage it and let me live out my destiny. So it's going to probably be an ACO look alike, but on steroids, where you have a population health management process, where it's got to be bigger than just the hospital. It's going to have a merger or a consolidation of hospital provider, payer, all saying we're going to collectively take care of a certain population. The other thing I think that's going to happen from the payer space is the rates. I don't think by 2049 we can still have Medicare rates, Medicaid rates, commercial rates and keep these three different reimbursement rates separately and try to get some semblance of equal access for everybody. Part of the rates, that differential between some of the programs that serve our population, leads to the inequities. So if I get paid lower reimbursement, then it's going to be a longer wait time to see a doctor, if I get paid higher reimbursement, I'll see that patient sooner. So I think there will also be a blending of some of the rates across the different programs, just for the sake of consolidation and trying to get more efficiency out of the system. That's where a payer can assist in this by being a collaborator and the convener of different parties and socializing the data to all those different parties so they can make the best decisions on behalf of the patients.

Jason Helgerson  25:43

So I want to go a little bit deeper on this topic because I think it's a crucial one and your perspective is very interesting. How consolidated, do you see that future state? I mean, you describe the sort of super ACOs, which sounds to me like Geisinger or Intermountain or systems like that, Kaiser, a lot of them have systems of that type. We've seen them around the country, these integrated delivery systems which have a payer and provider, is that the kind of organization? I mean, how many of those do you see in the future? That would seem to imply to me a more consolidated healthcare system than even what we have today? Or am I misinterpreting that?

Errol Pierre  26:33

No, I think that you're hitting the nail on the head. When you become big and you don't have connections to the local delivery system, it's very hard to move the needle on patient behavior to either take costs out of the system, or to drive better outcomes. So like I said, health care is local, I believe that in my heart of hearts. You're going to need these local systems that know the community, know the populations, have the staffing that's there to enable this work to happen. But I think today, we still are in our silos. hospitals don't interact with community physicians, community physicians and hospitals and payers are never collaborating around their specific population. Everyone believes they own the member, the PCP says I own the member, the hospital says that's my member. And the payer says that's my member. The only way this is going to work is when all the bodies are collaborating around it. So I do think yes, Geisinger, Kaiser, you can see the recent acquisition with SCAN and Oregon, I think there's gonna be more models like that, Kaiser doing their acquisition in Pennsylvania. More models where you're saying, I need to be local in my area, but then for scale, I have to have many of these local groups together, so I can have scale in multiple parts of the country.

Jason Helgerson  28:02

It's interesting, because I hear you and I hear the benefit of the local approach and tailoring services to the needs of local populations. But we had a guest on the show in Season Two, who is the Chief Medical Officer for Plume, which is a virtual primary care provider for transgender individuals. And the argument they were making was that they wanted to build a health care solution tailored to the unique needs of transgender individuals, and that the traditional local health systems, talk about a lack of cultural competence, or even a lack of clinical competence to really meet the needs of that population. And the idea being that they wanted to build a platform on a national and international level, and develop just super expertise in serving the needs of that population. I'm wondering, do you think that the local solution is right for all subpopulations? Or are there potential advantages, particularly with new technologies and things like that with so many services being brought into the home that people or providers may not want to be able to have that opportunity to have solutions really tailored to the individual's unique needs?

Errol Pierre  29:20

Yeah, it's a great question. So absolutely, to expect every locality to have a high level of expertise to serve a transgender patient, is that going to happen? So the ability to have something that's national and cross cutting, especially from a telehealth perspective, definitely makes sense from just a patient perspective and then also just from economies of scale perspective, so I get that. The one thing I will say though, is telehealth can only go so far, at the end of the day, if this patient has to get seen, they are going to have to show up somewhere and what tends to happen is these local air areas have to be the jack of all trades master of none. So, health care is not local, because we think it should be I mean, health care is local because people can only go so far to get their services. When I spent time at a for profit plan, we used to provide ideas to some of these major employers that had employees all over the country, the idea of either medical tourism, but even the idea of domestic medical tourism to say, hey, New York might be expensive for this procedure, we'll fly the member to Wisconsin where they can get the same procedure with high quality, and it'd be a lower cost. And it never picked up, even though it was an offering. People still, even though it was more expensive in New York, said I still want to get my surgery in New York. And then the person in Wisconsin was like, I don't want to go to New York, to get by surgery in Wisconsin. So it's human nature that makes health care local, not the fact that the industry wants to be local. I think people just feel way more comfortable being able to walk out their door and take less than a 30 minute ride to actually see someone and speak to them. Now, can someone like you said telehealth, can there be a screen in the home and they can talk to someone? Yes. But when you actually have to get seen, it's gonna go right back to the local delivery system.

Jason Helgerson  29:21

Gotcha. All right. So a final question for you is, I think you've been very, very articulate on the need to make changes today in order to get to a better, brighter future in 2049. If you could wave a magic wand today, what change would you make that would help to ensure that brighter future in the year 2049?

Errol Pierre  31:39

Yeah, that's a great question. My magic wand, it has nothing to do with health care, honestly. So we have a habit to put money at the symptoms as opposed to the root cause. When we look at the root cause of why certain populations have worse outcomes than other populations, or why medicine is inefficient, again it comes down to this such a strong correlation between health and wealth. So where I would put my bets is ensuring that the next generation of Americans that come into this country, they are well educated to be able to get high paying jobs, increase the median income, increase the middle class, they can get jobs in an environment where we're going to have way more automation. So that's my biggest fear of what jobs will they have as automation happens, and they have access to fresh fruits, fresh food, they can exercise, they can take care of themselves, they can build strong families. If we focus on those things, naturally, our healthcare costs will be lower. And if you look at Norway, if you look at France, Germany, all of the things that they focused on, their percent of GDP spent on healthcare is still 10-11%, nowhere near ours at 18-19%. Where they are spending the money, that's much higher than health care as a percent of GDP, is on social services and spending the money on social services turns into an ROI on health expenses. So my magic wand would be to actually make our social service programs much more fortified and better than they are today. And that will actually solve root cause issues of why we have health care disparities now,

Jason Helgerson  33:33

Great, on that optimistic note, we'll bring this session to an end. And that was Errol Pierre's vision for health in the year 2049. As always, thank you for listening to help 2049. If you enjoyed what you just heard, please subscribe to us on Apple Music or Spotify, and share this podcast with a friend. Thank you and see you next time.

Aaron Horovitz, Co-Founder and CEO of Empath Labs

How can innovative technology empower children to take an active role in their health care journey? Aaron Horowitz, Co-Founder and CEO of Empath Labs shares an approach to care that incorporates interactive companions and play to support the mental health and wellbeing of children. He envisions a future in which pediatric care is foundational in addressing population-wide health challenges. By engaging children in early prevention, we can create a more empathetic, personalized healthcare system at every stage of life. 

Aaron is a maker; from sculptures to business, he is fascinated with the process of taking an idea from concept to reality. His experience growing up with human growth hormone deficiency inspired a desire to bring empathy, design and a patient-centered mindset to healthcare.

He is the co-founder and CEO of Empath Labs (formerly Sproutel), a patient experience studio, and Design for America, a nationwide non-profit that leverages design thinking to create social impact.

Empath Labs is best known for their work creating Jerry the Bear, a best friend for children with type 1 diabetes, My Special Aflac Duck, a robotic companion for children with cancer and sickle cell disease, and the Purrble Companion, a toy to help people find calm. The White House and Barack Obama recognized Aaron as one of 50 honored makers in 2014. He holds a degree in Mechatronics and User Interaction Design from Northwestern University, a major he created to pursue a passion for understanding how people play with robots! When unplugged Aaron is likely either sculpting or surfing. 

Show Notes

• Aaron Horowitz shares his personal journey towards patient-centered pediatric care. [4:30]

• He shares a future vision that empowers children to emotionally engage with their care. [7:52]

• How can patients achieve better treatment outcomes? [9:39]

• Why have children been overlooked from a health care standpoint? [12:59]

• What’s the benefit of developing a preventative care system for children?[15:18]

• How can providers and insurers reframe their approach to engage with patients, particularly children? [18:30]

• When did Aaron know he wanted to design for pediatric care? [21:05]

• Innovative interactive companions that help children engage in their care. [23:30]

• What role can community engagement play in pediatric care? [27:05]

• How can we prioritize mental health for children? [28:30]

• How can mechatronics, technology and digital solutions be integrated into a child’s care? [30:15]

• Building in personalized care at every step of a child’s journey. [35:05]

Transcript

Bisi Williams  00:00

Hi. I'm Bisi Williams, you're listening to Health2049.

Aaron Horowitz  00:07

It all starts with how do we help the youngest children understand their health? How do we empower them with the right behaviors from the very beginning, so that they can grow up great. And what I believe is a key component to achieving that is a future where healthcare is equal parts health, and equal parts care. And in 2049, I see a future where we treat and take seriously the patient experience in the same way we do the actual life-saving treatments that people are getting.

Bisi Williams  01:58

Welcome to Health2049, the show that takes you on a journey into the future of health and wellness. I'm your host Bisi Williams and today we're diving into a fascinating topic that envisions a world where investing in pediatric care becomes the cornerstone of addressing population level health challenges at their source. Imagine a world where every child has the opportunity to thrive not just in the present, but throughout their entire lives. A world where we recognize the immense potential of investing heavily in pediatric care to revolutionize the health landscape for generations to come. My guest today is not just your average maker, Aaron Horowitz is a creative force to be reckoned with. From crafting exquisite sculptures to building successful businesses. He lives and breathes the art of turning dreams into tangible reality. But it's his extraordinary personal journey that truly sets him apart. Growing up with human growth hormone deficiency, Aaron experienced firsthand the challenges and struggles faced by those navigating the healthcare system. This experience ignited a deep seeded desire within him to revolutionize health care, infusing it with empathy, design and a patient-centered mindset. With his burning passion, he Co-founded Empath Labs, a trailblazing patient experience studio that's rewriting the rules of care. He is also the visionary behind Design for America, a nationwide nonprofit organization that harnesses the power of design thinking to create meaningful social change. Empath Labs has gained recognition for their groundbreaking creations like Jerry the Bear, a remarkable companion that supports children with type one diabetes. Then there's my special Aflac Duck, a robotic companion designed specifically for children battling cancer and sickle cell disease. And let's not forget the Purrble Companion, a delightful toy engineered to help individuals find calm in the chaos of everyday life. President Obama and the White House recognized Aaron as one of the 50 Honored makers in 2014. Aaron holds a degree in mechatronics and user interaction from Northwestern University. This is a major he created to pursue a passion for understanding how people play with robots. It is my pleasure to welcome Aaron Horowitz to help 2049 Aaron, welcome.

Aaron Horowitz  04:22

Thank you so much for having me Bisi.

Bisi Williams  04:25

It is such a pleasure. So now Aaron, tell us a little bit about your interesting background.

Aaron Horowitz  04:30

So, for me, the source of my passion for health care comes from my own experience. I grew up with human growth hormone deficiency. And basically that means that my body didn't produce the hormones that I needed to grow. So every day for about five years, I'd give myself a shot. And I just think back to so many moments in my own treatment journey, where I really didn't understand what was going on. I was sitting in a doctor's office and the doctor was talking directly to my parents, almost as if I wasn't in the room. And so I became really passionate about ways in which we can help empower children at this age. We are forming mental models of care and of their health, to help set them on the right trajectory as they grow up. And so when I went into college, you kind of highlighted, I founded this organization Design for America, which is all about using design thinking to solve problems with social impact within our own communities. And the very, very first project of Design for America was how we might improve the lives of children living with type one diabetes. And as we went out, and as we started interviewing parents and interviewing children, we saw that all of these kids would take their stuffed animals and give them diabetes, they would start injecting their teddy bears. They would start drawing little insulin pumps on pieces of paper and stapling it to their fur. And so children were really reframing all of the experiences around them through the language of play, through the language that they speak. And Piaget says, play is the work of childhood. And so this is what they were doing, they were doing the work of children to understand their experiences from a health care context in a way that was more intuitive for them. And for the past 12 years, we've worked through Empath Labs formerly through Sproutel to really bring that language of play to life for children in a health care context, to help them understand their health, for kids with chronic illness, and to help them really facilitate conversations and translations between the way that kids see the world and the way that we as adults see the world.

Bisi Williams  06:57

I have to say, you just touched me to the very core of my being, when you think about just watching your children or watching children and looking at them with care, and picking up what could be perceived as a subtle thing or play. But really understand that nonverbal language and that play language having so much meaning, that's really profound. And I just want to commend you for that. And I wonder, and this is where our conversations are going, how much perception is there in the medical and related spaces in terms of what people are feeling, what their environment is like, and how they understand what's happening to them. But I'd love for you to share right now with our listeners, your vision for health and wellness in 2049. 

Aaron Horowitz  07:52

Well, and maybe this is no surprise, but as I look into the crystal ball for 2049, it all starts with how do we help the youngest children understand their health? How do we empower them with the right behaviors from the very beginning, so that they can grow up great? And what I believe is a key component to achieving that is a future where health care is equal parts health, and equal parts care. And as we look back in the past decade, we've made these transformational steps when it comes to health, treating diseases, bringing the survival rate of cancer from 80% to 20% for kids, but the actual care side of health care has lagged far behind. And in 2049, I see a future where we treat and take seriously the patient experience in the same way we do the actual life-saving treatments that people are getting. And I'm really excited to get into what it means to really build this patient experience that helps put patients at the very center and help them not just receive health care, but understand health care and emotionally engage with their care.

Bisi Williams  09:23

I mean, that's such a beautiful vision and I'm gonna probe deeper on that and I just want to at a high level, I want to know why you are so confident that your idea or vision can be achieved in 30 years that we could definitely put the care in health care.

Aaron Horowitz  09:39

Gosh I think a lot of my confidence, I am a die hard optimist, so I have a lot of confidence in a lot of different optimistic futures. But for me, it makes so much sense because what is best for patients in this case, this improves patient experience directly in alignment with improved outcomes and cost savings. And I think that when those worlds align, when we can do well by doing good, those optimistic futures become realistic possibilities. So when we look at the impact of patient experience, we have documented research where we're able to show that when patients better understand their experiences, they have better outcomes, when patients have better communication with their doctors and their providers, it correlates to improved adherence and improved adherence to their actual treatment plans. So we have this key component of, hey, we can actually link these things through established research of making things better for patients, making the experience better, and actually having better treatment outcomes. But I think the broader meta narrative that gets me excited, is I think patients are getting fed up with the fact that the quality of experience that they're receiving in their health care isn't the same quality of experience they're receiving in any other aspect of their lives. And I think more and more patients are demanding that, hey, I interact with maybe my retail shopping experience in a current way, because at the end of the day, health care is a shopping experience. We're paying a lot of people now with these high deductible plans out of pocket for most everything that happens. And there should be an expectation and I think there is that luxury experience I might get when I buy a $1,000 good. When I'm going to the doctor's office, I'm buying a $1,000 treatment, right? I should get that same luxury experience, I should leave feeling good about myself, I should leave feeling like, I know what the next steps are in my own health care journey. And that's what makes me optimistic is I think people are coming around to that. And I think the more and more that we're paying out of pocket for our health, the more and more we're going to start demanding that we feel good about our health care experiences.

Bisi Williams  12:11

You know, you're so right, I love the way that you describe that I'll just share this. As a Canadian, we have a universal health care system, but when we moved to America, my youngest daughter became ill. But I thought the experience was great, because the rooms were decorated. They were clean. They had choo, choo trains and great diorama and stuff, which was something we just don't have in Canada. It's not designed to be like, oh, there's a slide ride. And I have to say that I was seduced by that. Meanwhile, there were serious issues underneath that. I'm going to come back to that with you. But why is your idea and your vision important? And how does it make the world a better place? 

Aaron Horowitz  12:59

Well, I think for many, many years, children have been overlooked from a health care standpoint. And if you zoom out and look at the dollars and cents of it all, you can see why children are not driving the bulk of health care spending. And simply because of that their populations are smaller, you look at the population of just type one diabetes in children versus adults. It's larger in adults and so there is this outsized focus on adult populations. But why it's important is that adults or just grown up kids, I mean, that sounds so obvious, right? But all of those behaviors, whether it's non compliance, whether it's maybe diet, exercise, all of those behaviors, go back to the mental models that we are forming as kids. And so if we really want to make a change, if we really want to flip the switch, and think about true prevention, we need to go back to childhood. And we need to go back to thinking about how do we not rewire someone's brain when they're an adult, but how do we wire someone's brain from the very beginning? Because kids are forming so many neural connections, and those are the patterns and behaviors, they will hold with them for their entire lives. So I think that this is critically important because it gives us the opportunity to think about systems level change.

Bisi Williams  14:30

Yeah, so I have to say, when you mentioned in the year 2049, we will invest more heavily in pediatric care as a means of addressing population level health challenges at the source, that statement blew my mind. It just popped and then and it flipped the way that I look at preventative care and I think you're actually putting in a new paradigm which is so exciting. You talked a little bit about it, but talk about it more. I mean, the fact that children are overlooked and not seen, but that kids are future adults. That's a very big idea, Aaron, and I think that this could actually get us very quickly to a preventative care system by investing in the youngest first.

Aaron Horowitz  15:18

Yeah. Well, I mean, I think just to start out, and thank you, I have so much heart and connection to you right now on this shared vision, because the way that we're currently thinking about prevention is, I think, almost prevention light. We're saying, Okay, you are an adult, and you're at risk for type two diabetes, let's think about altering diet and exercise so that you don't need to go on Metformin. And that is essential work. I don't want to minimize the importance of that type of prevention. But it's not addressing the root cause. And in order to address the root cause we have to go way, way back. And I think the best kind of foundation of research here is this adverse childhood events study, which has been going on I think, over 40 years, and it's looking at traumatic events that happen in childhood, one out of four kids experience a traumatic event and there is a direct correlation between those events and poor health outcomes, and worse physical health, worse mental health, more serious symptoms related to illness, higher stress hormones, reduced immune function. We have all of these linkages that go back to what is a traumatic event in childhood. And the definition for traumatic events is immensely broad. And so there are many reasons for why we're not doing this. And it is difficult to think about how you make investments when your return on investment might be on a 30 or 40 year time horizon. And so we push off doing these things, and the only way to start measuring the impact and to start making an impact is to start doing, even if it is a 1% change or a 2% change of investing in that pediatric health. So I think what it means to truly have prevention is to start addressing some of the softer aspects of health, some of the social determinants of health that surrounds childhood, investing in communities. And I can get a little bit more into detail with what that means. But it means investing in the whole health of the child. So not just children who are chronically ill, but children who might live in low income communities and don't have access to green space, or who don't have access to healthy food. Their mental models for how they eat and how they exercise as they grow up are all being formed in that zero to 12 age Group. And so it's going way, way back to the very, very beginning.

Bisi Williams  18:00

When you explain it like that, or and I just look at, wow, that's a societal missed opportunity and it makes my heart really beat. But let's dig deeper into patient-centered care. In what way do you see providers, insurers and Big Pharma reframing how they will engage with patients in the future and children in particular? How do we make it sexy for them to actually get on board?

Aaron Horowitz  18:30

Yeah, absolutely. We have to make it sexy, right for the people who ultimately stand to gain from the providers from pharma companies. We have to make this not the thing that they have to do, but the most attractive thing to do. And I think the core message there is brand relationship, it's brand loyalty. When you're able to provide an incredibly high quality of care to a child, that's something that their parents remember. I still remember I was on multiple drugs as a child, I won't name those companies, but I still have a fondness for some of those pharma companies, because of the way I was treated as a kid, decades later. I still think back to that company with fondness and I think the holy grail with brands is brand loyalty, it is word of mouth. These are the things that help whether it's a new pharmacological treatment spread within a patient community, or whether it's deciding which healthcare network to go to. Which provider network is going to be the one that resonates with you as a parent for your children. It's all about the softer aspects of care. It's way more important from a parent perspective. How you feel leaving it, how your child feels, even if the quality of care the actual health may be better at one provider, if you leave with a smile on your face, if you leave where your child is entertained in the waiting room, has less stress going into that blood draw, you will build a stronger relationship with that provider. So I really think that there is just this direct linkage with what is right for patients and the actual loyalty of that patient to your brand.

Bisi Williams  20:23

I feel such deep gratitude for the companies and for those medications that actually keep my children healthy and well. I'm so grateful for that. And it's weird, and I never really thought of it as like, Thanks, X Corporation, but I do. And I think you're onto something there. I want to go back to how your experience growing up with human growth hormone deficiency really inspires you. I mean, when you were five, did you think I'm going to do x? Or how did that evolution come for you.

Aaron Horowitz  21:05

I'll tell you Bisi, it was really organic and it's actually something I didn't realize until I was right smack in the thick of it. So as a child when I was asked I would always say I want to be an inventor. So this kind of desire to create was always something within me. But my healthcare experience, that experience going through human growth hormone deficiency was actually something that I was almost ashamed of, in a lot of ways. It's something I didn't tell anybody. Outside of my immediate family, my extended family didn't know, my friends didn't know, it was something I really held deep inside of me and was just this other piece of me. It actually wasn't until I was in college, and I was working on this project for children with type one diabetes, as you said in the beginning, creating Jerry the Bear this interactive companion for children with type one diabetes, I actually didn't realize why I was drawn to that. It might sound crazy. You'd think that I was instantly linking these two, it was actually when I was writing my first grant application for a small amount of money to continue prototyping, I had to run it by my team and there was a question that was why are you passionate about this? It was the first time I ever told somebody about my childhood experience. And I remember I was 20 years old and I was asking my teammates, Hey, can you read this and actually, before you read it, I have to tell you something. And that was the moment where those synapses in mind to borrow your terminology fired and I said, Holy Moly, I never connected these things. And now it's clear as day. Now I can look back, hindsight is always twenty-twenty and stories are always best told, when you're on the other side of these things and now the narrative is so very clear. But it was, I think, something that was moving me on a subconscious level all throughout my life towards this direction.

Bisi Williams  23:12

Which is so amazing, the power of invention, the power of design and the power of story. So I'd love you to tell us about your medical creations. Jerry the Bear, my special Aflac Duck and the Purrble Companion, tell us about these wonderful inventions. I love them.

Aaron Horowitz  23:30

Oh, thank you and I consider them my children to a certain extent. And so what all of these tools are is really personifying that key insight that I shared from our observation of children with type one diabetes, that children with illness use play to understand what's going on in their lives. What we do at Empath Labs is we leverage this methodology of giving children an interactive companion that they could mirror their medical procedures with. So each of these tools, whether it's our teddy bear for kids with type one diabetes, or my special Aflac Duck for children with cancer, children care for these companions in the very same way that they're being cared for. So in the case of diabetes, they're giving their teddy bear injections, they're feeding them foods, they actually have a blood sugar. So if you feed your teddy bear, a bean burrito, which you can, their blood sugar starts to go up, and you need to give them insulin. And so it gives this safe environment where kids can learn in almost a simulated way. But beyond that, for many of these children, they might not know another child who has that same illness so it gives them something else that they can relate to. They have these really profound roles within the home because what's happening is that all of a sudden the child goes from the person that's being cared for by their parents to the caregiver. The child becomes the caregiver for their companion so they actually step into the shoes of their parents. And it gives them this immense amount of empathy for why their parents are saying, well, you need to take your injection today, you need to check your blood sugar, and it reframes that whole conversation. So instead of parents saying, Oh, is it time to check your blood sugar? Is it time to take an injection, kids are saying, let's check the bears blood sugar, has the bear gotten insulin today? And then oh, now it's my turn. We have 125,000 companions all around the world in the US and Japan, in Europe, they're in use it 450 hospitals and this is the core use is children doing these medical procedures on their companions as a way of alleviating the anticipatory anxiety of helping them understand what's about to happen to them before they experience their treatment. And what that does, is it helps kids emotionally engage in their care, and it helps improve adherence, whether it's diabetes, whether it's cancer, whether it's self regulation, and self soothing, in the case of Purrble, helping kids calm down, it helps empower kids to really engage in their care.

Bisi Williams  26:13

It's that notion of physician heal thyself. This is so powerful in terms of beyond empathy is compassion, understanding for yourself. It sort of brings us self love, which is really important, too, vicariously through these tools, Jerry the Bear or your beautiful duck or your Purrble Companion. I think that's also part of the healing that you actually have someone to talk to. They understand what you're feeling, that there's that transference, but there's that love and tenderness, Aaron, that you've built into this, and that reciprocity of love and care. That is so huge. I just want to ask another question about what role can community engagement and collaboration play in pediatric care?

Aaron Horowitz  27:05

Well, I think just to touch on what you just said, that quality of acceptance is massive, is having something else that's experiencing the same thing as you. Children bring these into their school show and tell us, they're proud to talk about them. They're proud to show their friends how they engage. And it just is that small shift as human beings, we all have a personal narrative in our head of who we are and these companions just create that tiny shift in the narrative, that shift towards empowerment. I bring that up because it kind of ties into community engagement. I think community engagement is huge when it comes to pediatrics, especially when you're dealing with children with a chronic illness or children who are having maybe a health care emergency. It's not just about the parents, it's about the aunts, the uncles, it's about friends, it's about these almost concentric circles of your community that radiate out from the nuclear family into every single person that could pitch in. So there's this immense opportunity of engaging the community as kind of these softer rings of care.

Bisi Williams  28:23

That's a perfect segue into, how can we prioritize mental health and wellbeing in pediatric care?

Aaron Horowitz  28:30

I think the first step to prioritization is quantifying the linkages between mental health and physical health. We've been making progress there for years and we're just starting to really elevate mental health and kind of our Zeitgeist as something that is immensely important to address. We've seen a number of papers, especially in pediatric cancer, where you can actually directly link mental health to the actual outcome of the chemotherapy, so we're starting to see that if we're able to improve the mental health, improve the quality of life of children, as they're going through these treatments, it feels rather maybe intuitive that we would then improve health outcomes. We're just starting to see that. I think what it comes down to is having innovative centers of excellence, set this as a North Star and say, this is the way that health care needs to be for our children. And then have everybody else start to get in line. I think it takes the trailblazers to put this out at the forefront to start collecting their own data. Because no matter how many PubMed articles we're going to see that say this is something that can be done, we need the people to show us that it's something that should be done to really rally everybody together.

Bisi Williams  30:02

I am so aligned with you. And I wanted to ask you, Aaron, how can mechatronics, technology and digital solutions be integrated into pediatric care?

Aaron Horowitz  30:15

I think that there are so many opportunities. For us, we use these interactive kinds of robots, companions, call them what you might for children, they're toys for healthcare professionals, they're tools. We use them to create these ways of having conversation. Ultimately, I think technology is best when the actual technology fades into the background. So when we think about designing these tools, this is a little bit of a side quest, or a tangent to your question, but I'll come back to all the different ways that it can be integrated. We think about using technology, not for the sake of technology. But in the case of these robots, we think about creating the largest surface area for projection. These are not tools that are artificially intelligent, they're actually relatively simple. But children project onto that. Our Aflac Duck doesn't talk to children at quacks. Our Purrble doesn't speak in a language at purrs. Why? Well, we want kids to say, Oh, well, my duck is telling me this. And healthcare professionals will ask children, how does your duck feel, and the duck might quack and the child will say the duck is actually really scared about getting chemo today. It's like, Oh, why is the duck scared about getting chemo? And so we don't use technology to understand and intuit what the child is feeling and then communicate that on a back end data portal to show healthcare providers the integrated insights. No, we're using it to just facilitate these deeper conversations and to get to a place where we're able to allow children to open up because talking to children is difficult. It's difficult to really understand what's going on in their heads and how they're feeling. So I think that there is an immense opportunity for technology. Our companions are one example. But technology that can really speak to children at their level and get them to engage in their health in a way that is intuitive for them. So one example that I love is Akili Labs. They're the makers of this digital therapeutic. It's a game for ADHD that has clinical outcomes of improving executive function and improving focus. But it's a game, it's amazing, it's a game that kids play, oh, my gosh, this is a great example of giving kids a piece of technology that is not in the language of adults. It's not something for adults that's altered for kids, it's something uniquely suited to them.

Bisi Williams  33:00

You know something that you said here uniquely suited to kids. I think that there's a whole redesign that needs to happen if you start thinking about the full ecosystem of our child development. A child is really from zero to 21, ostensibly. I mean, there's that full development.  There are stage gates and I'm curious, I'll tell a story. My eldest daughter had a procedure and she is blessed with very long legs and a tall torso, so she's above average height. However, when she was at the hospital her head and her legs were hanging off the examination table. And that didn't exactly inspire trust or confidence in the procedure that was about to happen. And at the same time, you have these enormous imaging machines and these little tiny bubbles, so small, I just think could be, not fit for purpose for each stage. And if we are very serious about building a healthy, flourishing society, would we not then take these data points and as you talk about as the neural networks are growing in these children, and allow them to learn in the natural way that they do through play through observation, etc, to really kind of build a healthier empathic society that I would say, maybe it's a danger to the bottom line of the other companies, but you would see a huge reduction in the need for latter preventative medications or protocols. I mean, that's where my mind goes with this. Is that what you're thinking? Or am I off track?

Aaron Horowitz  35:05

No, absolutely, kids are not just little adults. And yet the way that we provide health care to children is often, not always, but often is treating them as little adults. And I think even looking at some aspects of pharmacological development where we're just saying, Okay, well, we're just adjusting the dose for kids. We're taking this drug for adults, we're figuring out and just decreasing that dosage. But I think that there's a little bit of the shift that you were highlighting with your daughter's legs hanging off the edge of the table. It's about personalized care at every step of the journey, maybe as you said, stage gates to these developmental milestones of childhood, to adolescence to teenager, continuing on upward. But really meeting people where they're at. Whether it's children, whether it's adolescence, and as they get older. I think we have this huge opportunity for personalized care, because perhaps the best way to treat children is both with that drug that is adjusted dosage for children. But perhaps it's also with other types of therapies, perhaps it's with mental health treatment that's provided alongside to help them better understand what's going on. What we look to often as the shining stars in health care are child life professionals. These are people in hospitals who are solely focused on the child's experience. If a child when they're getting an injection develops a coping plan with that child life specialist that says, I want to watch this specific YouTube video and I want the lights to be off. The child life specialist is the person that is in that patient's room every single time they're having a blood drawn with a laptop with that YouTube video loaded up, and with the lights turned off. The sad part is, this is not an insurance reimbursed profession within a hospital and it's donor funded at most hospitals. So it's limited to only those places that have that type of financial backing to make it possible. But the underlying therapy that they're providing is this aspect of personalized medicine that goes right along with treatments. At the start of this conversation, when I talked about health plus care that's what I'm talking about. It's the health, it's that medical treatment in the right dosage for the child plus care, plus all of the things around that treatment that create and help increase the effectiveness of the actual therapeutic.

Bisi Williams  37:40

Aaron I have to thank you so much for joining us today on Health2049. I am on fire with just inspiration and love for the work that you do. Thank you.

Aaron Horowitz  37:52

Thank you Bisi for creating this space and platform for me to share this because ultimately, it takes a village. These are massive changes that we're talking about and what gets me excited is hopefully igniting a spark in others to say, hey, pediatrics is something that we need to focus on because it's not going to be just one player. It's going back to collaboration. It's going to be so many people working together to make this vision possible.

Governor Jim Doyle, Counsel and Health care Lawyer with Foley & Lardner LLP

What role will state policy makers play in shaping healthcare? Governor Jim Doyle reflects on the future of healthcare and the role of governors in healthcare policy. He discusses the unresolved question of whether healthcare is a right for all Americans or an individual responsibility, emphasizing the trend towards healthcare being considered a right. Governor Doyle believes that technology will play a fundamental role in healthcare transformation, making it more efficient and accessible. He advises new governors to focus on getting people covered and addressing social determinants of health. In 2049, he sees governors continuing to play a crucial role in shaping healthcare policy and addressing challenges related to end-of-life care and increasing life expectancy, within the context of a federalist system that values state autonomy.

Governor Jim Doyle is of counsel and a health care lawyer with Foley & Lardner LLP where he provides strategic advice and counsel to clients regarding policy and regulatory issues in the areas of health care, energy and other highly regulated industries. Gov. Doyle served as the 44th governor of the state of Wisconsin (2003 – 2011). Governor Doyle was recognized as a national leader in health care, energy, natural resources, biotechnology and many other areas.

He has worked closely with the White House, high-ranking Administration officials and other governors. He has a deep understanding of the new laws and regulations being considered and adopted regarding health care and energy and works with clients to anticipate and comply with the evolving regulatory framework.

Prior to his election as governor, Gov. Doyle served 12 years as Wisconsin’s attorney general. He led the attorney general’s office representing the state in all matters. Gov. Doyle has led and coordinated major multi-state efforts and argued three cases before the U.S. Supreme Court. Prior to that, he was the Dane County District Attorney and a lawyer in private practice.

Show Notes

• Governor Jim Doyle shares his health care background. [03:33]

• Will health care be a right for all people and will public policy reflect that in 2049? [09:54]

• What will our healthcare system look like in the future? [11:34]

• What role will technology play in health care? [14:30]

• What did we learn from our fragile public health system during COVID? [19:50]

• Do people trust their doctor? [24:00]

• What should a new governor be focused on to help their state create a strong healthcare system? [27:44]

• What role will governors play in health care in 2049? [31:51]

Transcript

Jason Helgerson 00:04

I'm Jason Helgerson, and you're listening to Health2049.

Governor Jim Doyle 00:07

I think really, when you look at 2049, the biggest unresolved question for the country is, is health care a right? Is it something that we should be assuring all Americans of or is it some kind of individual responsibility that people have to take care of and that political fight is one that goes on and on and on. But if you look at the trend, the trend has definitely been more going towards the idea that it's a right.

Jason Helgerson 01:52

Today's guest is a highly esteemed figure in American healthcare having held one of its most important positions. Governors across America play a crucial role in shaping health policies and overseeing their state's largest health care purchaser, Medicaid. Meet Jim Doyle, the 44th governor of the state of Wisconsin who dedicated eight years to public service in his influential role. Throughout his tenure, Governor Doyle spearheaded transformational changes in Wisconsin's Medicaid program, leading to historic levels of health care access. When he completed his term an impressive 98% of Wisconsin residents, including all children had access to affordable health insurance. Presently, Governor Doyle brings his wealth of experience to the legal profession of counsel and a health care lawyer at Foley and Lardner. In this capacity, he offers strategic advice and counsel to clients specializing in policy and regulatory matters concerning health care, energy, and other highly regulated industries. While numerous individuals express opinions on health care structure and administration, only a few have actively shaped and executed it. Governor Doyle is one of those exceptional individuals, making us incredibly fortunate to have him as today's guest on Health2049. I'm Jason Helgerson, and you're listening to Health2049 and it's my pleasure to welcome Governor Jim Doyle to the program. Governor Doyle, welcome.

Governor Jim Doyle 03:21

Well, thank you, Jason. It's great to be with you again.

Jason Helgerson 03:25

That's fantastic. Well, first off, we always like to ask our guests to tell the audience a bit more about their interesting background.

Governor Jim Doyle 03:33

Well, the first thing I want to mention to those who may be listening is Jason was a Medicaid Director in my administration. And in that regard, really led the effort when we made the biggest at that time, the biggest expansion of Medicaid in the United States with a major waiver from the Bush administration at the time, that as Jason indicated, led in successive steps, we went through a number of them, but to having almost everybody in Wisconsin with access to affordable health care, and most people actually, in the mid 90% actually having health care. So I want to thank Jason for that. I will say I had to order him to take the Medicaid job. He was so valuable to us in some other areas, including economic development that he thought he wanted to stay in. So I feel a little responsible for how well he's done since moving to Wisconsin

Jason Helgerson 04:32

It's very true, Governor. It's a very true story.

Governor Jim Doyle 04:35

But I am really happy to be part of this discussion. I will just say that when I ran for governor, I had been the attorney general and in that world for 12 years before and a number of really significant health care issues had been focused on in the Attorney General's Office, most notably the fight against big tobacco. I was part of the lawsuits that were brought, we're the biggest in the country and they've had just a remarkable change in the health care of people in America. I just saw a numbers I may be off on this a little, but I'm sure there are basically right that in the mid 60s, into the 70s, about 60% of Americans over 60%, I think it was 64% that I saw smoked. And that number is down to 19. And it's falling very rapidly as older smokers age out of it, to put it euphemistically age out of it. So I really in large part got elected governor because of how the prior Republican administration in Wisconsin had handled the tobacco settlement that I had delivered to them. So health care was critical. But in my years, elected 2002, and re elected in 2006. So that first decade of the 21st century, health care really became in many ways the dominant political issue in America that continues to this day to be. So as Governor, we, as I indicated, had a major expansion of Medicaid. It was really innovative programs that again, Jason deserves a lot of credit for, to reach people who otherwise had not been eligible. Since being governor, I've continued to be involved in health care as a lawyer and consultant. But also I was the chairman for quite a number of years of the Kaiser Family Foundation, one of the real premier health policy, and now the largest health news bureau organization in the United States. And I'm on the board of several health companies. And maybe most notably, for this discussion, I'm on the board of Epic Systems, and of Exact Sciences, which is a company that really developed but is now pretty well known as cologuard, but other diagnostic, as well. So I've seen the side of it from the private business, as well, a little bit deeply involved in that. I will say, I will go wherever this conversation wants to go, but I think really, when you look at 2049, the biggest unresolved question for the country is, is health care a right? Is it something that we should be assuring all Americans of? Or is it some kind of individual responsibility that people have to take care of. That political fight really is, as you know, Jason, you've been in the political world for quite a number of years is one that goes on and on and on. But if you look at the trend, the trend has definitely been more going towards the idea that it's a right. So I think of the Epi Pen dispute a number of years ago, where people just generally were outraged, that private industry would put a price on the absolutely necessary health product that prohibited people from having it and I would say there was almost universal, both Republican and Democratic in political terms, but also just ordinary people just were outraged at the idea that a private company could put a cost on that. And I think that really demonstrates that I think most people culturally in this country believe that people ought to be able to get health care, although the rhetoric often goes in the other direction. But I think as you look at 2049, it seems to me the movement has been very much towards that. And so on the sort of political side of it, I think we'll continue to have fights for many years. But the long arc of this is towards health care for all and we are achieving it in fits and starts, large jumps forward for certainly in the 60s with the adoption of Medicaid and Medicare, large jump forward with the Bush administration with Part D, very large jump forward with Obamacare, but always resistance coming back against each of those. So I think that's kind of the long term political fight that we're gonna see going on into the middle part of this century.

Jason Helgerson 09:25

Well, that's great. So let's dive in a bit deeper on that question. I agree with you, governor, that the long arc history definitely bends towards health care being a right in the United States. Do you think we will achieve that by 2049? Do you think that by 2049, roughly 30 years in the future, there'll be consensus or near consensus in the United States that health care is right and as a result that public policy will reflect that?

Governor Jim Doyle 09:54

I think so. I mean, there may not be a moment where it's enshrined in the Constitution, that it's a right. But I think right now, it is pretty much universally available except for pockets of people that we, for various reasons–poverty, race, and others have left behind in this. So I think if you look at the big picture, we have largely achieved it with some very, very significant gaps that have to be addressed. Now, whether we've achieved in a way that's cost effective, equitable, delivering the best service in a timely fashion, those are all really good questions, which I think there are a lot of problems, and how we actually deliver it. If we just look at it come to a point, I think where we have it largely except for is significant pockets that we for various reasons have left behind.

Jason Helgerson 10:54

So around that, too, do you think that the way we get to it being a right in this country is through further incremental changes, meaning that the core structure which is a mix of government programs, employer sponsored insurance, some individual insurance sometimes subsidized with tax credits, like through Obamacare, that that sort of structure is what we still see in 2049 and with some of the further gaps being filled? Or do you think that there are more structural changes in how we purchase health care services, and the role of government in the purchase of healthcare services?

Governor Jim Doyle 11:34

I think there'll be some pretty fundamental changes, they won't happen in just a single moment. I think it's getting harder to justify insurers making significant money off of just administering the system. On the other hand, I guess maybe as a Democrat, this is a little counter thinking, but I do think when you look at the role of private companies, you can see that much of the real innovation, particularly as technology becomes more and more of the focus of this, it moves, I believe, moves much faster in an entrepreneurial environment than it does in large national kind of health systems. So I think we're going to continue to have a mix of all of this. But how the mix is balanced. I think we're gonna see some significant changes, I believe that we will end up at least, at a basic kind of Medicare for All idea that there's a basic insurance policy that all Americans have that the government pays for. Whether the government then delivers that, even 25 years out, I think it's hard to see in America, that it'd be the government delivering it in the sense of a large European national health system. But I do think there will be a basic government payer for a basic policy. It seems to me that's really where we've been headed. Although that gets beaten back pretty forcefully, every time Bernie runs on that issue and gets pushed back all the time. Well, actually, it's kind of clear what he runs on. But whether it's a big national system or Medicare for All, I think we probably in America end up with a Medicare type of system for everybody.

Jason Helgerson 13:37

Okay. So the role of technology and as you mentioned, even the work you're doing today is very focused in the sort of technology and innovation space of health care, both actually nationally, and the companies, you're on the board of sell internationally, and so we often get into this question about the role of technology in health care in 2049. What is your view relative to the role it's going to play? Are you seeing it as really, truly transformational in the sense that the actual patient experience or the role of the provider, the physician, the nurse, will be fundamentally different in 25 to 27 years? Or do you see technology is playing a role but not quite so fundamental in terms of really changing the user experience?

Governor Jim Doyle 14:30

I believe it's fundamental. And I think if you just look back at the last 25 years, I know you're the son of a doctor, but think how critical a doctor was 25-30 years ago in reading all the journals trying to stay up with all the most recent information, hearing about a difficult case from going to a conference and hearing about it was something that happened three months ago in another state and then trying to follow up to see if that would apply to the difficult case that this doctor is dealing with. All of that is done now with the data that's available. Those difficult cases can be found in the matter of seconds. The doctor, this already happens, the doctor just on the electronic health chart, can see what the recommended treatments are, for something the most up-to-date information is immediately at people's fingertips. So the great value of a doctor who had, and I will say largely his head at the time, but now his or her head, which was absolutely critical, you were just lucky to be with a doctor who was working at this all the time, trying to stay up-to-date that's now available to every medical professional in the world, there is certainly in most in most countries. So I think that's already changing and that's only going to continue to change. Does anybody doubt anymore that the most important thing you do in the annual physical is going to give your blood test and then the doctor looks you over a little bit. But the most important thing is what that test is and what we can determine from that test. So I think the diagnostic world is changing rapidly and obviously the data world is changing enormously. This was certainly in your days when you were in Wisconsin, that we had one of the best public health reporting systems, we always bragged it was the best in the country, because we had automated much of it. But the automation was hospitals sending information to the county, the county sending information to the state, and the state sending information to the CDC. And while we had automated most of it, and we would brag about that, there were states that and I assume they may still be there that had paper records in their county health department's. So when COVID comes around, to try to deal with that system to find out what's happening with COVID, how many hospital admissions were there yesterday for COVID? What happens to people who got the vaccine age 50 years old who have certain comorbidities? What happens to them six months out from the vaccine. That was only available months later, that is now available in real time. So I think technology is changing this dramatically. And also, just the advances of science. People often say it's so expensive, compared to back in the 1960s, I could go and pay a doctor 50 bucks and get a visit. Well, that's true, but you weren't getting nearly the service that you get now. Our health system, if you look at where we were 25, 30, 40 years ago, compared to now, it's a very, very different system, it's a much more effective system, the treatments are better, the technology is better, the data is better, the diagnostics are better. With AI and other technological advances that's gonna move even faster than it has over the last 25 years.

Jason Helgerson 18:28

Yeah, actually one area, you just got into a little bit that I wanted to pick your brain on and see what your thoughts are is in the public health system in the United States and governors also really, to great extent, serve as the chief public health officer for their states, and are the ones who manage the response to public health emergencies. And I think that role was probably underappreciated until the pandemic, to the degree to which, and we saw across the country governors responding to the pandemic in fundamentally different ways. But I think we also saw some of the weaknesses of that public health system in the United States. Especially when it was comparing the US response to what was happening in other countries, but what are your thoughts on the public health system and what that system looks like in the future? Do you think we will learn from the mistakes or the underinvestment in that system of the past, things that showed up very clearly in the pandemic? Or maybe are you not as optimistic that we will really use this crisis in this horrific incident as a learning experience for this fragile system we call public health?

Governor Jim Doyle 19:50

That's a great question and my opinion on this isn't any better than anybody else's. Our response was very heartening in many ways and very disheartening. But clearly the under investment had us in a very bad place. Just our crisis, our triage, public health system wasn't ready to go by any means, as we know what happened in New York City and in some of the early places where the horror was really just there hitting people, as they watched people being carried out of their homes, and so on. So I hope we've learned that but I'm not sure. I've often thought, who is going to get hurt politically out of the response? So if you look at the DeSantis campaign, right now, he's going after Trump, because Trump somehow in the DeSantis world was too accommodating to the public health people on COVID. DeSantis stood up against all this public health garbage that was coming on. And then you look at the statistics. I noticed that, I don't want to get to picking candidates here, but the Governor Sununu, Republican, of New Hampshire, New Hampshire had one of the absolute best records. So I would love to see those two face off on a COVID debate. Because I looked at these numbers once and I don't know that I remember them exactly. But Florida basically four times the people die per capita that New Hampshire had. So politically, how does that play out? Is it good for the governor who really did follow protocols, put in lockdowns at the critical times, require masks? Do all they could to get people vaccinated? Is that Governor gonna be rewarded? Or is it the governor who said I stood up against all of that? And I think that's a big political divide in America. And I'm not sure where it comes out. That political divide, I think, is going to kind of determine whether we learn and do things based on COVID or not. You've probably heard this, but I have heard people say it, it's almost a joke, to say, we're never going to do that again. We're never going to do that COVID thing again. Well, I hope not. But we really don't have any say over that, if the next virus hits us, the next pandemic hits us. We can't go back to having that just be a political response. So I just think this is really an open question right now, whether we will learn and really build a strong public health system, or whether the recriminations are just so harsh that everybody will run away from it.

Jason Helgerson 22:51

Yeah, and I guess my concern, my fear a little bit is that the pandemic has politicized, not just public health response, so like mass requirements, and stay-at-home orders, and all those kinds of things, but it's also politicized the clinical components and the clinical response to viruses. And we've had a long history in the United States of of anti-vax feeling, but I almost feel like this pandemic has exacerbated that and my worry is then that will ripple through to the healthcare system, and to the health of the public. And I'm just wondering what your thoughts are relative to that, the knock on effect to clinical care and people's views of clinical care and the advice they're getting from clinicians. Are you concerned that the politics of all of this is really going to fundamentally affect, do people trust their doctor? I mean, I'm just wondering what your thoughts are on that.

Governor Jim Doyle 24:00

I think there's no doubt. I mean, just take the vax before COVID, the anti-vax movement was a weird little thing that went on in certain communities, but nobody really objected to having their kids getting all the multiple vaccinations that are needed to go to school and so on. And you think of all of the horrible diseases that we've eliminated through vaccinations, and I think now, I wouldn't call it mainstream, but it's almost mainstream to be anti-vax. So, yeah, I think it's a big issue. The personalities of this, the politics of this are difficult to deal with, I think the big decision that was made by the Trump administration that was really bad on this was to turn it back, when Trump found out that this was really much more difficult than just it's going to be a way we're all going to be in church on Easter, then he just punted it to the states. And I think if we had had a really good, strong national response, that was sensible, that was medically related, I objected to some of the things Fauci did, not the scientific things he did, but going on Saturday Night Live, and he clearly seemed to me to be enjoying a public kind of public figure. And that's not what his position should be, you've got to really protect the sanctity of the science of all of this. And so I just think a lot of people made it worse. But I do think the really fundamental decision that you alluded to earlier in this discussion was sending it to the states where the governors were doing all these different things. It turned out to be deadly for a lot of people, if you were living in states where governors were just resisting it. Back in the middle of it, I looked up a couple of these states that were so proud that they were open for business like South Dakota. I remember comparing South Dakota with New Hampshire, because it's two states, roughly very small populations, largely ethnically white, in many ways, similar in the demographics, not similar in the politics, and the death rates were multiple times higher in South Dakota than they were in New Hampshire. So as you know, as everybody knows, this virus didn't care what state it was going over. So I hope the one basic thing we learned is, if this happens, again, you need a good, strong national response, you need an international response, but you certainly need a strong national response.

Jason Helgerson 26:45

All right. So Governor, a question has just come to mind that I'm now dying to ask you is, let's just say governor could be a Democrat, could be a Republican, could be from a Midwestern State, East Coast, West Coast, Southern comes to you and seeks your advice, they just got newly elected, what would be your advice to them in terms as they look forward and begin to embrace their role in health and health care looking forward to the year 2049 into the future and how they can best position their state for for success and protect the health and well being of their citizens? What should that new governor be focused on, that would really help position their state for having a strong healthcare system in 2049, or a really healthy population in that same year?

Governor Jim Doyle 27:44

Well, I don't know if many would take my advice on this, but the way I saw being governor is, if you're a governor of a state, you're not going to remake a national health system. This is how I saw it, it's really not up to you, you can talk about how health reform should happen on a national stage and so on, but the real role you have is to try to make sure the people of your state have access to health care. And so again, with your help, Jason, a lot of what we did was, well who are the people that don't have it? Under the Medicaid system, the so-called childless adults didn't have it. So how do we expand to people that didn't have children, but needed it? Then we found, particularly in the recession period of time, that a lot of people were out of work, and they didn't apply to Medicaid. So we were able to extend our basic Medicaid program, they had to pay, but they paid on a sliding scale. So I saw it as a matter of looking at what are the needs and how do you practically find the resources to meet those needs? Some governors get into these big political fights in Wisconsin, as I think you know, and of us, just gall you, we don't take the enhanced Medicaid money from Obamacare and it's just absurd. Even Missouri, South Dakota had a referendum, all these very conservative states at stake. And so why don't we, because the Republican members of our legislature who control think that it will make people dependent on the government, so for political reasons they're keeping people away from having health care. Again, I don't know if this is advice to governors, but I just think the role of a governor should be to try to get people covered. Interestingly, in Wisconsin, again, as you would know, but I was recently with Governor Tommy Thompson, who later went on to be the Secretary, and we've done a number of these things together now where we talk about it, but he started the Badger Care Program in Wisconsin. At that time it was really an important part of the Republican welfare reform, which was to expand Badger Care so people with higher incomes who are working have access to it. That was part of welfare reform. It was accepted widely by Republicans around the country. And he built a program that was very good. And when I came in, it was growing, and we expanded it dramatically, and moved it into other places. But the basic core was a Republican governor that had a Democratic legislature and our big expansion happened with a Democratic governor, and we had one house that was Republican, we needed Republican votes to do it. So I would encourage governors not to get into this partisan fight over it, and to really just be looking at what they can really do to help the people of their state. What you need to do, I think, we know this, I mean, it's pretty basic stuff, you really need to make sure you have healthy pregnancies and good birth, you need to make sure there's good health care in early childhood, that there's good, and all of the other things, all the social determinants as well as are much more important than the clinical part of medicine, but there's food and housing and good education and the things that really are going to determine what a person's lifelong health are. And you've got to work against the basic tobacco and other things that young people will be tempted by as they go along. And you want to really make sure that there's a good basic health care system in your state, which we've been blessed with in Wisconsin. Our basic health providers are very, very good in this state, and always have been.

Jason Helgerson 31:51

Well, great. So one final question for you, governor, and that is what role will governors play in health and health care in the year 2049? So do you see the role of the governor changing roughly 25 years into the future? Or do you see it roughly the same? Just looking at your successors in the future, what do you see their role being?

Governor Jim Doyle 32:20

They're going to have a very important role, I think one of the things we see as the federal nature of our country is very strong. And that we saw it for maybe for worse durning COVID, but the the demand for states to make their own decisions is a very, very powerful force in this country, and will continue to be. Our federalist system isn't going to go away in 25 years. You've had others who are much more visionary on this, but the data will be much more powerful. Some of the really fundamental issues that states are going to deal with, and these will be state issues, are how you deal with death. When you continue to spend the highest percentage of your healthcare spend on the last few years of life, it isn't very sustainable in the long term. We can see this now states are dealing differently with assisted suicide and other kinds of issues that are very difficult to talk about, but I think are really critical. Our technology means that and the scientific advancements that maybe they can get us to live to 110 or 120. But I guess the question is, what's that life like from 85 or 90 to 110? Those kinds of issues we have left to the states and I think will be really fundamental for governors in the future to be dealing with.

Jason Helgerson 34:06

Well, thank you, Governor. And that was Governor Doyle's vision for health in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.

Dr. Deana McDonagh, Professor and founder of the (dis)Ability Design Studio, Beckman Institute of Advanced Science and Technology

What if we could harness everyday surroundings, such as our homes and workplaces, to actively monitor and improve wellbeing? Dr. Deana McDonagh, Professor and founder of the (dis)Ability Design Studio at the Beckman Institute of Advanced Science and Technology, envisions a future that includes personalized medication and nutrition in wellness-centered home environments. Her work focuses on evolving the notion of "disability" and instead emphasizes designing for diverse abilities. As a visionary industrial designer, she shares the importance of experiential learning to cultivate empathy in creating a more inclusive and emotionally sustainable future.

Dr. Deana McDonagh is Professor of Industrial Design in the School of Art and Design, Health Innovation Professor in the Carle College of Medicine at the University of Illinois Urbana-Champaign and founder of the (dis)Ability Design Studio at the Beckman Institute of Advanced Science and Technology. The Studio is based on the principle of designed 'by' rather than designed 'for' model which embraces people living with disabilities as contributors to knowledge rather than research subjects. She is an Empathic Design Research Strategist who focuses on enhancing quality of life for all through more intuitive and meaningful products, leading to emotional sustainability. She concentrates on the emotional user-product relationships and how empathy can bring the designer closer to users’ authentic needs, ensuring both functional and emotional needs are met by products.

Show Notes

• Dr. Deana McDonagh shares her background as an industrial designer focused on empathy to enhance our understanding of other people’s needs. [3:10]

• Her journey to implementing empathy into her design work. [4:20]

• A view of future wellness that includes innovative products and features in our homes. [5:31]

• How can our clothing contribute to wellness in the future? [08:46]

• How do we design for ability instead of disability? [10:13]

• Innovative, holistic product design that will disrupt the industry. [12:40]

• Designing services, environments and products that actually build in emotional sustainability. [16:37]

• What is emotional sustainability? [19:30]

• How can we integrate this beauty in design for those who are marginalized or underserved? [23:21]

• What does the future home look like? [24:36]

• How can people experience the notion of kindness and empathy? [28:36]

Transcript

Bisi Williams 00:00

Hi. I'm Bisi Williams, you're listening to Health2049.

Deana McDonagh 00:09

It's about kindness. It's about empathy. And it's about acknowledging that in this moment, we may be able-bodied, but all that can change in a moment. That sensitivity to the human condition. And not only looking at the needs of today, but looking at needs of tomorrow means that we're going to be designing services, environments and products that actually build in emotional sustainability. So people feel like these objects, services and environments are actually designed for them in 2049, not just in 2023

Bisi Williams 01:50

The human body is a complex system. It has numerous inputs and outputs, and most of the body's mechanics and wiring are invisible. What if we could make the invisible visible? What if we could use our passive environments like our homes and workplaces to actively measure our well being? My guest today is an empathic design research strategist who focuses on enhancing quality of life for all through more intuitive and meaningful products. Dr. Deana McDonagh is the founder of the disability design studio at the Beckman Institute of Advanced Science and Technology. She's professor of Industrial Design in the School of Art and Design. She's also Health Innovation Professor in the Carl College of Medicine at the University of Illinois, Urbana Champaign, Dr. Deana McDonagh, welcome to Health 2049.

Deana McDonagh 02:59

Thank you, I'm so excited to be part of this.

Bisi Williams 03:03

We're excited to have you on the show. Would you please share with our listeners a little bit about your fascinating background?

Deana McDonagh 03:10

Well, I am an industrial designer and my area is empathy, empathy as a portal to more enhanced understanding of others. If we focus only on the functional side of people's needs, then we're really missing emotional connections and so I am truly a professional optimist. I'm always looking for those disconnects from what should be to what is experienced and the bridge I found between the concrete lived experience of all those things that can be measured and the things that can't be measured. The bridge really is empathy.

Bisi Williams 03:56

I think that's the most important thing. And what I love about what you do is you connect the dots. It's not just a function. It's also beauty, delight and joy, which I think is also superduper important to living and designing our lives. So how did you become an empath, if you will, about your design work?

Deana McDonagh 04:20

Well, I am an industrial designer, and numerically the field is male dominated. I realized the products, everything that surrounds us tends to be designed not for anyone like me. Then I was focusing on the female voice in design. And then I realized, well, firstly, there is no average person in the world, from a human factors point of view. Nobody has an anthropometric standard body size. What's more important is that the females in the Northern Hemisphere tend to be the majority but when our voice isn't heard, it's a fact that we are less likely to survive a plane crash, a car crash or train crash, because the material landscape is not designed for people like us.

Bisi Williams 05:19

I think that's fascinating. We can talk a little bit more about that. But what I'd love to hear and I know what our listeners are excited to learn is, what is your vision for health and wellness in the year 2049.

Deana McDonagh 05:31

So 2049 is an exciting time. Because we have transitioned from blaming everybody else about our physical challenges to being proactive, we have a health service that is all about preventative care. It's about motivating the individual rather than punishing the individual. It's about not just focusing on mobility, but focusing on wellness, joy, sense of belonging. And so let's talk about the whole. Let's talk about the fridge, the refrigerator now has a shelf, dedicated to skincare, dedicated to lotions and potions that may have sensors in them that actually really figure out from a dermatology point of view, how the epidermis, how healthy it is. Also, the fridge is really controlled for your medication. And the medication is actually bespoke, imagine 3D printing, imagine now we 3D print our medication, because you get a prescription that was years ago, and your body has changed, the chemistry has changed, the season has changed. But has the medication changed? The food that you eat can be 3D printed, that can be enhanced with certain nutrients and vitamins that the whole system in your home is saying you have a deficit or surplus of. And then we move to the final frontier, which is the bathroom. I could talk about the bathroom for months on end. I don't know if it's because I'm European, well I was European when I left the UK. I'm not sure if I'm called European now. But what fascinates me is that we flush away critical data every morning in urine and feces. Stop me Bisi if I'm talking too much about this.

Bisi Williams 07:53

No, no, it's not too much TMI.

Deana McDonagh 07:55

So I am looking at toilet paper that has sensors in it. So it can detect blood. I do bring toilet paper from the UK that has moisturizers in it and is scented. So the experience is joyful. But also we can build in technology. Imagine you step into the shower, the shower measures you and keeps an eye on your weight, it captures any of the skin and hair samples that fall off in the process of your shower. And also imagine sensors, I don't want to say cameras because that will freak people out. But if you live alone, and you can't see your back, how do you know if you've got a dermatology issue developing?

Bisi Williams 08:42

I love that and tell us more about the clothes.

Deana McDonagh 08:46

So it's 2049 you put your clothes on, the clothes repel mosquitoes, they repel bees, whatever you're hypersensitive to and clothing can have actuators in them that can help with mobility, like imagine exoskeletons, but they're so subtle and refined. Also, your clothing can have slow release medication. I mean, again, I think we're going to be more nomadic in the future. And so your clothing, the bathroom, your medication, all of that has to be really, really tailor made. And I don't want to focus on living longer. I want us to focus on a total commitment to prevention in a very organic way. So we don't become uber obsessed, so it gets in the way of us living our lives. But I think the clothing, the bathroom, our home environment is going to be the epicenter of wellness going forward.

Bisi Williams 09:56

It sounds divine. I love it. I'm down for all of that, especially if it's beautiful and it's fit for purpose. And so why are you so confident that your idea and vision can be achieved within 30 years?

Deana McDonagh 10:13

Well, I am always forward looking, I'm immersed in the disconnect of the here and now. And as an industrial designer, I'm always looking to cross pollinate, to bring people together that have never even considered looking that far into the future. My space here at the Beckman Institute for Advanced Science and Technology is really the epicenter of interdisciplinarity here at the University of Illinois, where it brings in sciences, medical experts, and engineering. From last November, I founded the Disability Design Studio, and so on the disability, the dis in disability is in brackets, because I want to get rid of deaths, I want us to only design for ability. And that ability may be dynamic and ever changing. But if we focus on death, then we're always putting down people that may look and sound and behave differently to us. So what makes me optimistic is that I am passionate about products, services and environments being designed by people who are diverse in their abilities, rather than the privileged few designing for them. And here at the Beckman, I'm shifting the culture from people with disabilities as research subjects, to people with disabilities as being contributors of knowledge and that is a portal to innovation.

Bisi Williams 12:02

1,000,000% I have goosebumps all over my body, I can't tell you how excited I am about that, just those three words, erasing them from our vocabulary. And looking at the dynamic range of human experience and designing for it. I really think that you're on the forefront of this, looking at it holistically. This is so exciting. And so would you please share some examples of the products that you've designed and that your future designing, if you imagine for 2049.

Deana McDonagh 12:40

So we are designing the wheelchair of the future. It is a bowl bot, imagine a bowling ball with lots of systems that it's omni directional, it's hands free. It's a smaller footprint than any existing wheelchair on the market. And it's designed by coach Adam Blakeney, who is the USA Para Olympic coach for track and field. And we're partnering with phenomenal engineering colleagues and this is his vision. He's a wheelchair user, and we're instilling empathic design, human-focused and that's just one of the projects. This really is going to be hugely disruptive going forward. The other thing that we're finishing off right now, and I don't know if any of you have experience of traveling with a wheelchair user, but they're often first on the plane, their chair is taken away from them. Imagine you're on the tarmac, there's delay, they desperately need to use the restroom. They have to crawl to the restroom. So it's inhumane. It strips them of dignity. And if any of you have been on a train, a coach or a plane toilet, the last thing you want to do is crawl on that floor. So what we're designing, and it's been designed by coach Adam and two industrial design undergrads that are both wheelchair users. We are designing a personal, it's a mobile chair that they can take on with them. So if they need to move around, they have dignity. It's a flat pack, it opens up when you need it. And it is literally designed by them and there are other things. So I'm dealing with medical students and I'm working with the pediatric ward. And so I bring medical students into my design studio. We talk about disconnects and you have a different kind of conversation. When they're in a design studio, that's playful. That's got a decal all over the wall. I mean, it's playful. And also, I think you'll love this. If you want to come and have a conversation with me. The conference table is surrounded by assistive technologies, you have to sit in a wheelchair to have a conversation with me.

Bisi Williams 15:41

Wow, okay, you're just blowing my socks off. I can't tell you how informative you are. What a revolution I had no idea and I don't think our listeners did either. In terms of what people who use different mobility tools have to go through is staggering to me, and I can't wait for your chair to be on the market, so that they can move freely about the plane or the train. That's just unbelievable. And so awesome. I'm so inspired. You're just getting started. So why is your vision and idea so important? And how will you make the world a better place for everybody?

Deana McDonagh 16:37

It starts with the understanding of the importance of kindness. So I teach the medical students, just to give a couple more seconds of looking in the parents eyes that have a sick child. I ask them to think about how they can bring joy into any of the interventions they're going to introduce into the pediatric ward. It's about kindness. It's about empathy. And it's about acknowledging that in this moment, we may be able-bodied, but all that can change in a moment, you slip on the stairs like I did a few years ago, and three operations later, I was determined to sleep in my own bed, I was crawling up and down the stairs. I was living my research and that was humbling. I thought I was humble enough, but apparently not. But I do believe that people that have a different lived experience and that could be as temporary as a migraine, or super stress or loss of a job where your whole identity is turned upside down, that sensitivity to the human condition and not only looking at the needs of today, but looking at needs of tomorrow. And the unforeseeable needs means that we're going to be designing services, environments and products that actually build in emotional sustainability. So people feel like these objects, services and environments are actually designed for them in 2049, not just in 2023.

Bisi Williams 18:45

Can you say that, again, I think that's super important that you actually have an emotional attachment that you value the objects in your life, for work, and play and rest. I think in the design field, we forget about that. We need to think long term. When you think about a tool that gets you from A to B or like when I think about a laptop, things that enable you to live with purpose and dignity. Can you talk a little bit more about the longevity of those, but also the joy in there. I think that those are important design concepts.

Deana McDonagh 19:30

Well, they are critical. So I talk about emotional sustainability and emotional sustainability is beyond what the product is made of. So we all know bamboo products that are sustainable but some products are single use. So that to me is not sustainable. If we focus on the human needs of today, tomorrow and the unforeseeable future, then what we're doing is ensuring that the emotional connection, the person feels that this product is really serving them through the various lifespan. I look at the material landscape and there is a sociology of the living room, for example. And everything that we surround ourselves with if it's clustered together, like family photos, or if it's a taboo product, like anti dandruff, that's hidden away when family are coming. All your dirty washing is removed from the dining table, we elevate certain products, like your awards or your certificates, because we need that in our space. So think of your home as hugely symbolic. Think of textures, colors, how agile is the space? How can you move the furniture around if you have a guest or a friend coming who's a wheelchair user? Or you in the future? On a personal level, having a shower, it's sensorial it's joyful. How many people have different types of shower gels, potions and lotions, depending on, do they need to be refreshed, do they need to calm down, do they need to wash the day away or do they need to be soothed and calm? And brushing your teeth, make it fun. Why do the children have all the fun? Why not buy a toothbrush that brings you joy and toothpaste that sparks joy and is a flavor that really activates your tastebuds. And so the home environment, and where you work, and equally how you dress are all opportunities to bring joy to ensure that there's wellness being practiced in your day to day.

Bisi Williams 22:16

I just want to live in your world. That sounds amazing. I've already moved, this is fantastic. I think one of the things that is so important when we think about our future is beauty. I'd love to talk to you a little bit about this when you talk about sustainability. And yes, we are super blessed, and grateful for the resources we have and I'm curious how we marry that. And when we think in 2049, we'll be at 1 billion people. How do you imagine that we integrate this beautiful world for all of those that are maybe marginalized or underserved? And then how do you imagine we highlight this? I feel that making a wheelchair an object of beauty, it's transcendent. Those are innovations. We have art, science and technology. Can you talk a bit more about that from high scale to low scale.

Deana McDonagh 23:21

So that's a PhD question. It's maybe three pH, PhDs, but it's 2049 and so we've done the groundwork. So how does this look? I think we are obviously moving away from McMansions, we are really considering the footprint that we consume. And I think the smaller home with higher quality materials, and more of this meaningful consumerism. I think we're going to almost go back to the Old English small houses, and Hamlet's and let's imagine the Hamlet is a small community that may have a medical expert, a nurse, a doctor, some caregivers, and it's transgenerational, and objects are shared amongst the communities. We have people that are dedicated. We have to get rid of built in obsolescence.

Bisi Williams 24:34

Thank you.

Deana McDonagh 24:36

And I'll explain why this could work. Let's imagine a family of four people, parents, two children. Let's keep it simple. One of the children likes their toast a certain way, they get a modular toaster. As they leave to study or work away, maybe they start their own micro family, then the other person's micro toasters module comes together. And we've got two slots for toast. And then as they have children, it adds on. But equally, there's a modular system to everything we own. I mean, there's no reason why every house in America needs a lawn mower. I am an American, despite how I sound. Americans have an incredible sense of playfulness and the pursuit of pleasure and yet they have a garage full of toys that they do not have time to play with. I think we are moving away from home ownership as we know it. The home is going to become a wellness retreat. I treat my own home as a retreat. It's sacred. It's where I close the door on the world, but not my community, and the colors and lighting, so for example, the lighting in my studio here at the Beckman, it's the opposite of the scientific labs. There's no overhead, I have these big globes, I have cuckoo clocks that go off because some people don't have vision. So I want the passage of time to be organic. I have kinetic furniture that moves. If you come and visit me, I have those little stress relievers, those little squeegee things, that you can have a conversation with me and your nervous energy is being channeled into, do you know what I mean?

Bisi Williams 26:49

I know exactly what because I have the same things.

Deana McDonagh 26:51

So the home and living in the future, I don't think we need the choices we have in supermarkets. I think we need to scale everything down. I think food is going to be more dynamic, and rather than just consumed to fill us up, and I think the super functional is going to be what drives us, the super functional involves the emotional, the aspirational, the cultural, because the cultural imprint is really what drives our decision making. We can throw on top any rationality you fancy at the moment, but a lot of our decision making is really based on our very early experiences and that's the cultural imprint.

Bisi Williams 27:43

I love this future and how it actually seems more humane, more life centric, not just human centered, it's really taking into account all of life. And what's interesting about your scenario, is that we have more of what we need, which is connection to friends and family, to nature, to our purpose, which is also a remedy for health. And as you talk about all these preventative measures, there are things that we can do for $1.95 that really bring us to wellness. And I love the notion of kindness and empathy. And it sounds easy. Is it easy to do?

Deana McDonagh 28:36

Well, we have to acknowledge that there are some personality types, and that some people do not experience empathy or can develop empathy, in the same way as the majority of people. And then there are some people that make it very difficult for me to want to personally be empathic with on any level. And that's a challenge, but I think it starts with a smile. It starts with acknowledging, so I have an empathic gerontology suit. So for example, I can take a 20 year old, typically healthy, able-bodied student, I can layer them with so many disabilities the body cannot overcompensate. So I can give them tinnitus, simulate glaucoma or retinitis pigmentosa, and I can make all their joints relatively immobile. I can make it so they can't feel the ground so they're shuffling. I put a 40 pound weight on them. I put weights on every single ankle and wrist. I then ask them to do an activity of daily living. Not only is this onslaught of the body has now augmented their experience, they now realize how difficult everything is, any activity. What this does in 10 minutes, it transforms them, it transforms a typical able-bodied person into their future self. Or the experience of a loved one that does need more time searching for the right credit card or the right change or can't quite hear you. So what that does in the minute, it is very emotional. It takes people really deep into themselves. And through that experience, and I've done this for companies, everybody should go through this. I've done this around the world can you believe for medical experts that have never done any empathic modeling, on the very patients that they serve. Going back to this, it opens up our reservoir of empathic understanding that would not have been there unless it had been untapped. And so this sticky, experiential learning, the individual takes this into their professional life, their personal life, and they actually carry the torch and kindness, understanding and patience doesn't become a burden. It becomes part of who they are.

Bisi Williams 31:42

Deana, thank you so much for your joy, your empathy and your wisdom. It has been an absolute pleasure talking about the future of health and wellness with you.

Deana McDonagh 31:57

Oh, I think I'd give you a hug right now.

Bisi Williams 32:01

I'm giving you a hug, thank you

Annie Lamont, Co-Founder and Managing Partner of Oak HC/FT

How will healthcare innovation and the role of venture capital shape the future of healthcare? Annie Lamont, Co-Founder and Managing Partner of Oak HC/FT, a leading healthcare investment firm, emphasizes the importance of young, innovative companies supported by venture capital in driving change in the industry. She discusses the need for integrated healthcare financing and delivery, focusing on primary care and value-based payment models. Annie envisions a future where healthcare is delivered in homes through technology and virtual care, with hospitals specializing in acute care. Despite challenges, her optimism about healthcare innovation and value-based care models prevails. Explore the future of healthcare with this insightful conversation.

Annie Lamont is a Co-Founder and Managing Partner of Oak HC/FT where she focuses on growth equity and early-stage venture opportunities in Healthcare and FinTech.

Annie currently serves on the Boards of Advise Health Holdings, Brightline, CareBridge, Main Street Health, Modern Age, Quartet, Rubicon Founders, Truepill, Vesta Health and VillageMD. She is a Board Observer at Precision Medicine Group. Annie is also actively involved with Devoted Health, Komodo Health, Notable, and TurningPoint Healthcare Solutions.

Her prior investments include Aspire Health (acquired by Anthem), OncoHealth (acquired by Arsenal Capital Partners), OODA Health (acquired by Cedar), Poynt (acquired by GoDaddy), American Esoteric Laboratories (acquired by Sonic Healthcare Limited), Argus Information & Advisory Services (acquired by Verisk Analytics), athenahealth (NASDAQ: ATHN), Benefitfocus (NASDAQ: BNFT), CareMedic Systems (acquired by Ingenix), Castlight Health (NYSE: CSLT), CLARiENT (acquired by GE Healthcare), Health Dialog (acquired by British United Provident Association), iHealthTechnologies (merged with Connolly to become Cotiviti), Independent Living Systems, NetSpend (acquired by TSYS), Oak Tree (acquired by Oxford), Odyssey Healthcare, PayFlex Systems (acquired by Aetna), PharMEDium Healthcare (acquired by CD&R), Point Carbon (acquired by Thomson Reuters), Psychiatric Solutions (acquired by Universal Health Services), TxVia (acquired by Google), United BioSource (acquired by Medco Health Solutions) and Vesta Corporation.

Annie has been featured on Fortune's Private Equity Power Players list, Barron's 100 Most Influential Women in U.S. Finance list, Forbes' 50 Over 50 list, WSJ Pro Private Equity’s Women to Watch list, Fortune’s Top Investors in Health Tech list, Private Equity International's Women of Influence in Venture Capital list, Modern Healthcare's 100 Most Influential People list, Institutional Investor’s FinTech Finance 40 list, CB Insights & The New York Times’ Top 100 Venture Capitalists list, and Forbes’ Midas list. She was the first recipient of the National Venture Capital Association’s award for Excellence in Healthcare Innovation. Annie was also honored with the Healthcare Private Equity Association’s Russell L. Carson Award for Lifetime Achievement in Healthcare Investing. She also served on the Stanford University Board of Trustees and the Executive Board of the National Venture Capital Association.

Annie received a Bachelor of Arts degree from Stanford University.

Show Notes

• Annie Lamont shares background, starting with her early entry into the venture capital industry. [03:35] 

• She attempts to suspend listeners' disbelief as she shares her vision for health care in 2049. [04:47] 

• Where should health care be delivered in the future? [08:45]

• Will we have a virtual first system? [11:01] 

• Will technology be responsible for the first line of care? [12:49]

• What will be the role of the doctor and nurse? [14:26] 

• Where will health care innovation come from? [17:54]

• How can companies scale and grow to a critical mass to serve communities? [21:29] 

• What’s the role of insurance companies in 2049? [24:24] 

• What will be the role of the hospital? [26:10] 

• Will the healthcare system be more or less political? [28:15]

• What will the politics around local hospitals look like? [31:12] 

Transcript

Jason Helgerson 00:04

I'm Jason Helgerson and you're listening to Health2049.

Annie Lamont 00:08

Innovation is what the venture capital community does. And I think when you're a legacy company it is very, very hard to disrupt, to actually rethink how things are done to get the talent that's focused on how to rethink things are done and then break things and improve things and break things in healthcare. I'm very much about, people are involved, these are human lives we're touching. So you can't break care delivery and you cannot break that side of it. But I think rethinking some of the approaches to care delivery will really only happen or 80% will happen with young innovative companies supported by the venture capital community.

Jason Helgerson 01:40

Annie Lamont is a highly esteemed healthcare investor, as Co-Founder and Managing Partner of Oak HC/FT, one of the leading healthcare investment firms in the country. Annie brings a wealth of knowledge and experience to the table. Throughout her entire career, Annie has dedicated herself to investing in groundbreaking companies, making her a true authority in the healthcare landscape. Her keen understanding of the industry and where it's going enables her to stay ahead of the curve and identify promising opportunities. Annie's accomplishments extend beyond her investment prowess. Annie has been a trailblazer for women within the financial industry and often serves as an inspiring role model for female professionals. She has been featured in Barron's 100 most influential women in US Finance, Forbes 50, over 50, and the Wall Street Journal's private equity Women to Watch. She has also received numerous industry awards, further solidifying her status as an outstanding figure in her field. With her exceptional experience and exposure to cutting edge ideas in health and health care, there couldn't be a more fitting guest for our show. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Annie Lamont to the program. Annie, welcome.

Annie Lamont 03:23

Thank you, Jason. Love the intro. Thanks.

Jason Helgerson 03:27

Well, in addition to the intro, there's a lot more to your story. Maybe you can tell our audience a bit more about your interesting background.

Annie Lamont 03:35

Well, I went to Stanford and got out of Stanford at the time when Silicon Valley was really in its nascent state, but beginning to have green shoots. And I was fortunate to enter the venture industry right out of college, in the form of boutique investment bank, venture firm that took Apple and Genentech public in the first three months that I was out of school. So it's been really wonderful, over 30 years and in the venture capital world, and there's nothing more satisfying than working with entrepreneurs and helping dreams come true that actually positively transform the world. So I've been incredibly fortunate.

Jason Helgerson 04:20

Well, great. So very excited to have you on the show today because as I said in the intro, your background and experience and the fact that you see really new ideas coming across your desk from entrepreneurs, or would be entrepreneurs basically on an everyday basis. I think this positions you well to answer the core question we ask all our guests, which is what does health and healthcare look like in the year 2049?

Annie Lamont 04:47

I love this because hopefully I can suspend listeners' disbelief as well as mine in terms of the current state of health care. Let's actually start from the regulatory framework, because that is so much how we finance healthcare, and how we measure it is so impactful in terms of where we're going, and I am affecting people's actual individual daily health. What I'd start with actually is from a government perspective, we really need to look at all the conditions which create poor health and affect our health. When you think about those, like financial buckets, housing, mental health, new food, think about different programs around nutrition, the SNAP Program, employment workforce, all those things actually, at the end of the day, affect our health, and yet, they're all in different buckets. They're not in HHS, they're not CMS when you think about HUD and SNAP Programs, everything is spread out across the government. In my dream world, including Medicare and Medicaid, the fact that Medicaid is run by states and is different in every state, and Medicare is run obviously federally, that if you could put Medicare and Medicaid together, not every head of Medicaid in every state would be happy, perhaps with my saying hat. But I think the reality is, if you look at dual eligibles, and where the sickest are, this convergence and coordination, and how we finance, health care, all really needs to be in one bucket. And if you can put all of those financial resources and link those capabilities together, that would be a good start and incredibly powerful. From an innovation standpoint, and how we have to think about financing at an impacting behavior on the ground with just specifically the medical profession, I am so all in on primary care, or doctors and providers taking risk, and owning a patient for a very long period of time. If you don't and are not responsible for the total cost of care, and for the quality outcomes of your patients, then we're never really going to change the system. And I think that is fundamental, we have beginnings in terms of primary care doctors taking risk on patients that are beginning and it's really just in the Medicare Advantage bucket that people are doing that successfully right now. But I think we need to think of it much more holistically and have a population that is driven by primary care and the doctor side of it, where they're actually financially aligned to think about your overall health over the long term versus coming at it from a payer perspective, that's completely separate from the care delivery model itself.

Jason Helgerson 07:56

Great. So two, I think big themes there. One is the convergence, particularly in the public programs and trying to get greater uniformity across the country and bringing those two giant payers Medicaid, Medicare together. And then the move to value-based payment and aligning incentives and hopefully empowering those primary care providers to do everything they can to keep people out of hospitals, two really big key themes. Let's just say for instance we achieve those things. What could that potentially unlock or mean for actual delivery of care in terms of the patient experience, the provider experience? If we achieve your bold vision for financing, what do you think that would then ripple through to in terms of how services are actually providing carers experience?

Annie Lamont 08:45

Okay, so if you think about how care should be delivered in the future, care should be delivered in your home. We spend very little time in a doctor's office, hopefully very little time in the hospital. And what we should be doing is influencing the day to day behaviors of individuals and supporting them in their homes, and in their daily lives. And so when you think about care delivery, certainly 30 years from now, we will have sensors, we will have prompts, we will have the ability to help people manage their health care day to day. We will have caregiving, most of it virtual, and everything should be about the least cost setting to deliver the care. Obviously it should be about impacting the quality of care, but if you can create something where we are experiencing support for our health care day to day, versus thinking about it as that episodic visit to a provider, then that is where you're going to get the bang for the buck, the impact on our health outcomes, as well as far cheaper support system for health care.

Jason Helgerson 10:03

Right, so this idea of moving more services out of institutional settings, even out of doctor's offices and back into the home and using technology to make that reality a very compelling, exciting vision, certainly from the patient's perspective of the convenience of not having to leave their home for care. How far do you think we go in the next 30 years in the sense of, is our healthcare system in 2049 a virtual first, meaning that the first point of care or where we try to get our services met is virtually in the home? Do you think we get to that point where almost everyone is receiving services in that way, first and foremost? Or do you see more of a hybrid system where individuals continue to go to doctors offices as a first point of care, just interested to see how far you think technology will go in 30 years?

Annie Lamont 11:01

I think it will be virtual first, think about holograms, think about all the technology that can be used, where we can diagnose people, and we can help experience them in a more realistic way. If you think about 3.0 3D, as we think about virtualization, it's really going to take on a different, 3D perspective than it has today. I don't think we're going to obviously eliminate in person, there are elements that one needs, once we get into the stage of actually doing things to people, then you're going to have to see them in person. On the diagnostic side and the prognosis side, I just think that most of that can be done virtually. I think in 30 years, we will absolutely be in a world where we can support people through technology where that is allowed. I mean, that is not so that I don't think in person interactions are valuable. I think today they're very valuable, people having that human connection, incredibly valuable. But I do think through technology, we are going to be experiencing each other in a different way in 30 years.

Jason Helgerson 12:13

And then along those lines, how much of that virtual care is actually provided by humans, just through a virtual portal, versus how much of that you think is actually provided by machines with artificial intelligence and such, advancing obviously at a pretty rapid rate today, but 30 years in the future, even more advancements, how much do you think that first line of care for your average individual person is actually not by a human being but by a machine?

Annie Lamont 12:49

Well, I probably have a different answer today than I had a year or two ago around that. And I do believe that these MLMs, chatGPT, openAI, I think that large language models will change things dramatically. And while I don't think the replacement of doctors is the first thing that's going to happen, I think it'll be more about initially, workflow, automation, efficiency, really more administrative, but I do think that it's going to work its way into clinical more rapidly than people would think right now. And so I think even 10 years from now, there's going to be a number of first interactions that can happen quite successfully with Generative AI.

Jason Helgerson 13:40

Interesting, and I agree with you, I think that my view on the issue has changed as well in the last 12 months. And then my view in terms of the future is even continuing to evolve and feels like almost daily in terms of how much additional change is going to be seen. But all of this suggests that potentially a changing role of the doctor, the changing role of the nurse in the healthcare system, with these advances in technology and artificial intelligence, do you see that the role of the doctor in the healthcare system, let's just start there, do you think that role is going to be fundamentally different than it is today? How will technology affect what they do on a day to day basis?

Annie Lamont 14:26

I think initially technology depending on what kind of a doctor you are, if you're a surgeon, or to replace that will take a long time. Some surgeries can be assisted through robotics, but I do think on the front end, we need to leverage the primary care system that we have. So I think in most cases this will be an augmentation, making doctors more efficient, allowing them to focus on the direct clinical care as opposed to the administrative side of it. I think, on the nursing side, I do think that there are so many nurses in call centers now responding to questions where a lot of that in the future can be done through automation. through Generative AI, and I do think that nurses in person will be more important, nursing in the hospital, direct nursing care supporting those who are truly sick and truly in need of either surgeries or treatments. My hope is that most nurses are actually in that in person function, and the things that we can do with nurses that are knowledge base that can be automated, that that happens, that that becomes a more automated function in the next decade or two that's supported by technology.

Jason Helgerson 16:03

Yeah, I agree with you. One of the things that makes me optimistic about technology is that the World Health Organization came out with a global study that said by the end of this decade, based on the current models of healthcare globally, we're going to be somewhere between 18 and 20 million short in terms of the number of healthcare workers, and that there's virtually no way for us to train our way or educate our way out of that global shortfall. And that the only real way to meet the needs of an aging population, a growing population is automation. And so I think in some ways, my view is that whether some people like it or not, we have to automate, we have to change the rules, and we just won't be able to keep up with demand otherwise. But one of the other questions I've been very eager to ask you about is you said you started your career in venture capital, and in the early very formative period of Silicon Valley, and had been involved in this ecosystem of early stage company, how do you view the role of the private sector, the role of early stage companies in sort of achieving your vision? Do you think the big ideas, the new innovations, the new care models, are they going to be coming from these new companies, these new early stage companies as opposed to say, for instance, your big insurance companies or your big hospital systems, the sort of traditional dominant players of American healthcare and how big of a role do you see this early stage, the sector playing and in creating the new, better world?

Annie Lamont 17:54

Honestly, I think it's the only way we have innovation occur in health care. And I think you can almost prove that out by looking at other countries that are driven by hospital systems, where there's virtually no innovation in Canada, the UK, they're certainly looking to us for the whole model of virtualization home care, and how do we think about the evolution of that? And I think that while venture capital and private equity have gotten, for some reason, a bad name, I think people feel like not-for-profit, healthcare versus for-profit, health care, is highly different. I think the reality is there would be very little innovation without the venture capital community in healthcare. And I will say if you think about not-for-profit healthcare, like in hospital systems, the reality is for-profit versus not-for-profit, there is nothing not-for-profit about a hospital system where every decision is made by a doctor who is actually for-profit. So I think that it's actually a very strange moniker that really is very little different. Other than, certainly there are hospital systems in parts of New York City, where a for-profit may not go. But I think beyond that, if you sat in the boardrooms of for-profit versus not-for-profit hospital systems, they would sound exactly the same. So I'll leave that aside. But I think the reality is innovation is what the venture capital community does. And I think when you're a legacy company, it is very, very hard to disrupt, to actually rethink how things are done, to get the talent that's focused on how to rethink things are done and then break things and improve things and break things in health care, I'm very much about, people are involved, these are human lives we're touching. So you can't break care delivery, and you cannot break that side of it. But I think rethinking some of the approaches to care delivery will really only happen or 80%, let's say happening with young, innovative companies supported by the venture capital community.

Jason Helgerson 20:17

All right. Well, I agree with you and I'm very optimistic that not only are some of the companies that have been created in the recent past that are now maturing and growing, scaling, but also new ones that will come, ones that we don't even see yet. Maybe you see them, but most of the rest of the world hasn't seen them yet, and will also be at the vanguard of innovation. But I think one challenge that a lot of these companies have faced has been that challenge of scaling, that the health care tends to be a service that's provided on a local regional basis and a lot of those nonprofit hospital systems have monopsony power and make it very difficult for new entrants. But that's changing and we are seeing some scaling, we're seeing some success in models in various markets and in types of services and I'm just wondering what your thoughts are on, as you look to the future, the ability of these companies to scale to grow and get to a critical mass in service in communities that they really do supplant, replace, threaten the status quo?

Annie Lamont 21:29

I agree with that. So it's interesting, we actually have invested in very few companies that sell products, software, to hospital systems, for example, because it's a very difficult world to sell into, what we have done is either create providers ourselves that are thinking differently, or I think we've backed 28 payer facing companies that are sometimes providing a service in a different way, or sometimes are principally software that are automating things. But I do think that it is possible to create companies that are not part of hospital systems, and healthcare systems that actually create change. And it could be as models like Aspire was in reinventing palliative care, thinking about it differently, where you're providing, in that case, we're providing virtual care, supporting those who are probably not going to live past a year or two. And they were identified through either their doctors or an algorithm that said that and it wasn't, you're immediately going into hospice care, it was, let us help you and support you so that you don't end up in the emergency room seven times this year. Let us make your life easier, let's support you virtually and in home and make the journey for the caregiver, whether it be a family member or the individual who is dying, let's support you in this journey. So, I think there are companies like that, you don't have to really worry about the local hospital system, because you're just providing a service that's needed and is supportive. We could go on and on in terms of mental health care, and social determinants of health where we're working with payers in various markets. So I think there are many different ways to go about this without actually selling products to hospital systems.

Jason Helgerson 23:41

Gotcha. So the dominant players of American healthcare for the past, however, many decades have been insurance companies and hospital systems. I'm interested in what you think those two actors look like in 2049, let's start with the payers with the insurance companies in terms of what they look like in the sense of, are they continuing to play a similar role? Do they evolve because of virtual care into actually providing more direct services? Or do they contract with organizations in fundamentally different ways? I mean, what do you see is the role of insurance companies in the year 2049?

Annie Lamont 24:24

Well, I don't know if you're familiar with Devoted, but Devoted is a Medicare Advantage plan right now, across many states, essentially driven by virtual care and then linking into local care, they started as payer, and they're becoming providers. And if you think about what United has done with Optim and the number of providers that they have purchased and are now part of their system, I think in the end, I think they're are thinking correctly, that the reality is if you're not integrated, if you don't own a large portion of the primary care and some specialty in America, this taking risk on people's lives, that you're not going to be relevant in 30 years, that that is the way the world is going. I think the payer's see that. And you've got to really integrate care delivery with risk, because that is going to be the most powerful way to take the most cost out of the system and take the best care of individuals. If you're just a payer, trying to impose on people, it’s very difficult.

Jason Helgerson 25:44

Gotcha. So then let's move to hospitals in the sense of, I've personally said that I think in 2049 we might not even call them hospitals, because the fundamental role that they play in the system will be very, very different. And we may actually have a different name for them. But maybe that's a little controversial, but I'm wondering what your thoughts are relative to the role of hospitals and 2049?

Annie Lamont 26:10

Yeah, if we're just focusing on the hospital portion of healthcare systems, I think that the hospital just becomes more and more acute. There's no question that we need great acute care, ICU, general acute care and taking care of individuals, certain surgeries that are very serious need to be done in a hospital environment, we want the best excellent care in America. And so I think what's going to happen is, you're going to have fewer and fewer hospitals, but you are going to have hospitals that are dedicated to the most extreme needs of the population. The rest will be done outside the hospital system and will be supported and even right now, I mean, you have ambulatory surgery care, so many surgeries can be outpatient, don't even need an overnight stay. We're already evolving that every day. I'm always amazed at how many ambulatory surgery centers are continuing to be created, that there is a continual need. And every day in every specialty, we're perfecting surgeries, and allowing people to move out of the hospital setting faster and faster, which is brilliant.

Jason Helgerson 27:28

So one final question for you, Annie, the subtopic that we frequently talk and ask our guests on is the role of politics in health care. And it definitely feels as if health care in some fundamental ways become more politicized, of late as from the Affordable Care Act, but even beyond that. I'm just wondering what your thoughts are. Do you think health care is going to be less political, more political, about the same in the year 2049? And do you think that the political debate of today and the political nature of health care today, do you see that potentially as an impediment to your otherwise very positive view of the future?

Annie Lamont 28:15

That's such a great question. I would say. It's interesting. I think that on the drug side, you're beginning to see green shoots there. There's a little bit of consensus between Republicans and Democrats on that and trying to control drug costs. Now, we do have the most amazing innovation engine in the world. And we all want to benefit from that, both of my parents died of Alzheimer's and absolutely, I want biotech and pharma companies investing in that. And so my view is, we need the rest of the world to pay up, we are subsidizing the rest of the world. So I think the feds are gonna have to take that on and when they negotiate globally, and get to the G20. Like this is never on the table, it needs to be on the table. So, I think that is, let's just put that aside. But I think the thing I see that's most intransigent and most difficult is the stranglehold of hospital systems. If you think of analog, we have wonderful hospital systems in Connecticut and across this country that are doing great work, but I do think there is, if you look at the boards, most of their boards are often local individuals that are protecting the monopoly and that is very challenging. And so I think change is extremely difficult when it comes to moving the dial in terms of how hospital systems are formed. Closing a hospital is, even if there's a hospital 15 or 20 minutes away, closing a hospital is extremely difficult because people love their local hospital systems. So that just creates a cost problem that is very hard. Citizens don't understand that. All they know is they want their hospital 10 minutes down the road, that gives them comfort, and I really understand that. So I think that's going to be probably the biggest challenge is how we think about our hospital systems because they're loving, and other than Walmart, hospitals and healthcare systems are the largest employers across America. So they have an enormous amount of clout from their local boards to also the number of people they employ.

Jason Helgerson 30:47

Yeah, absolutely. Are you optimistic that the politics around your local hospital will have changed by 2049? In the sense that maybe technology or others will have changed? Maybe the perception of how health care could and should be provided and less institutional focused? Or do you think that we'll still be struggling with that issue as a political challenge in the future?

Annie Lamont 31:12

Well, I'm a venture capitalist, so I'm always optimistic. I think that will continue to be a challenge. I do think that hospitals systems and there are many of them that are thinking about being more value-based, creating more arrangements, I think there will be more because of the aggregation of primary care doctors and specialists across the country that are creating a countervailing force to hospitals themselves. And I do think that there are hospital leaders and we have them locally that are absolutely thinking about, what does the world look like in 10 and 20 years? And how do we make sure we maintain relevance and do the right thing by our patients. So I think ultimately, we will get there.

Jason Helgerson 32:01

Well, great. Thank you so much. I appreciated a wide ranging conversation and covering a lot of ground in our 30 plus minutes, but thanks so much. And that was Annie's vision for health in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe on Apple Music or Spotify and share this podcast with a friend. Thank you and see you next time.