Our Plants Should Be Plants

It seems like most of my healthcare Twitter buddies are enjoying themselves at HLTH2022, so I don’t suppose it much matters what I write about, because they’ll all be too busy to read it anyway.  That’s too bad, because I was sparked by an article on one of my favorite topics: synthetic biology. 

Credit: Shutterstock

Elliot Hershberg, a Ph.D. geneticist who describes his mission as “to accelerate the Century of Biology,” has a great article on his Substack: Atoms are local.  The key insight for me was his point that, while we’ve been recognizing the power of biology, we’ve been going about it the wrong way.  Instead of the industrialization of biology, he thinks, we should be seeking the biologization of industry.

His point:

Many people default to a mindset of industrialization. But, why naively inherit a metaphor that dominated 19th century Britain? Biology is the ultimate distributed manufacturing platform. We are keen to explore and make true future biotechnologies that enable people to more directly and freely make whatever they need where-ever they are.

He cites Gingko CEO Jason Kelly’s 2019 tweet:

"X doesn't grow on trees" ... biology is so much better at manufacturing than any human-invented tech that we use it as an idiom for free and abundant. if we all do our job well in synthetic biology everything will grow on trees.

Dr. Hershberg asks, “So…how do we get to a future where everything grows on trees?”

That’s a great question.  Remember, although the first definition of a plant is typically about living organisms like trees, flowers, and grasses, the second definition is about industrial factories, as in “a place where an industrial or manufacturing process takes place.”  How do we transform our grimy, polluting, resource-intensive factories into, well, trees? 

That’s the power, the potential, of synthetic biology.  He points out: “Biology manages to adapt and grow everywhere and is capable of both atomic precision and enormous scale. In other words, we inhabit a biosphere that is capable of producing more than enough to meet our needs.”

Dr. Hershberg’s title “Atoms are local” comes from bioengineer Drew Endy mantra that “biology teaches us that atoms are local;” i.e.,

The leaves on a tree don’t come from a factory and then get shipped to where the tree is going to be and taped and stapled to the twigs and branches. The photons and molecules arrive where the biology is going to grow and the biology grows locally.

Dr. Hershberg expects that within our lifetime we’re going to have DNA printers that produce any desired DNA sequence, and “desktop bioprinters” that use DNA sequences to print proteins, which could ultimately lead to a “personal biomarker” that could, in Dr. Endy’s words. “enable people to more directly and freely make whatever they need where-ever they are.”

That’s a “wow.”

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I’ll give a few examples of advances in synthetic biology in just the past couple weeks:

• “MIT researchers have developed a new way to precisely control the amount of a particular protein that is produced in mammalian cells.  This technique could be used to finely tune the production of useful proteins, such as the monoclonal antibodies used to treat cancer and other diseases, or other aspects of cellular behavior.” 
• Researchers from Technion-Israel Institute of Technology and MIT have developed “cells engineered to compute sophisticated functions -- "biocomputers" of sorts,” thuis creating “genetic "devices" designed to perform computations like artificial neural circuits.”
• Scientists at the Swiss Federal Institute of Technology have developed “bionic bacteria” that can deliver cancer-killing compounds precisely to tumors, and, once there, “you basically have a little nano-factory that continues to release molecules that can be toxic to cancer cells,” says one of the authors. 

The field is advancing on multiple fronts, at dizzying rates – faster than we’re reimaging what we might do with it.

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Meanwhile, Stat’s Matthew Herper warns that “we’re not prepared for the next wave of biotech innovation.”  Although he, too, is a believer that we’re living in “biology’s century, he fears: 

the biggest looming problem is that we will simply become lost and confused as to what works and what doesn’t, scuttling our own progress, wasting money, and missing opportunities to save lives. That’s what happens when new technologies in biology outpace our ability to assess them.

He worries that, in particular, our system of clinical trials is way too slow, way too expensive, and way too inconclusive to deal with the pace of innovation we’re seeing.  I like his analogy:

U.S. health care system tends to believe that inventing brand new gadgets is the answer to everything. The result is that we try to solve problems by building faster and more expensive Ferraris when what we really need are better roads. As a result, our sports cars end up stuck in the mud.

“Politicians and regulators outside the health care industry need to start to think about what success and failure look like in medicine,” Mr. Herper suggests, and “We, as a society, will need to change our understanding of what is true and what is not. The world's going to be transformed — we can't let our thinking about it fall behind.”

Credit: StatNews

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Mr. Herper was making a very different point than Dr. Hershberg, but I think the commonality is that, while we’ve embraced synthetic biology/biotech in terms of industrializing biology, we still have not made that conceptual leap to biologization of industry.  How do we revamp, remake, our various industries – not just healthcare ones -- to use biology as the core for production?

As venture capitalist Tom Baruch predicts: “We’ll see synbio disrupt every industry, whether building materials, agriculture and food, chemicals, medicines, water treatment, and environmental engineering.” 

Dr. Hershberg believes that combining synthetic biology with the internet means that “the marginal costs and distribution costs of actual material goods in the physical world could come to approximate the costs of distributing software products on the Internet.”  In other words, “one of the major lessons of biology is that planetary scale distributing manufacturing is possible.”

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If you’re not paying attention to synthetic biology, you need to be.  If you’re not thinking about how it is going to change your industry, you’re going to be disrupted by people who are. And if you’re only thinking about incremental changes, within our existing conceptual models of what biology is and can do, then you’re not thinking nearly big enough. 

Trees as factories, for almost anything we want.  Get ready for it. 

And You Thought Mastodons Were Extinct

Until last week, for me, “mastodon” only meant the giant animal that went extinct several thousand years ago (I was, it appears, unaware of the heavy metal band Mastodon).   Now, as the result of Elon Musk’s purchase of Twitter, many Twitter users are being forced to take a look at alternatives, such as the social networking site Mastodon.

It’s possible that we are about the witness the Myspace-ization of Twitter, brought down by competition, bad management, and bad product decisions.  In my usual “there must be a pony in here somewhere” fashion, there may be some lessons in the Twitter saga that healthcare might want to pay attention to.

As most know by now, Mr. Musk has been a Twitter power user for many years, and a frequent critic.  In March of this year he started discussions about purchasing it. In short order, he threw out a bold bid, was rejected then accepted by Twitter’s board, tried to get out of the deal, was sued by Twitter, and closed the deal late last month. 

Then things got really rocky.   

Mr. Musk tried to reassure squeamish advertisers, only to make them and others even more nervous when he retweeted some disinformation.  After a spike in hate speech on the site, he promised that, as much as he was buying Twitter out of his love for free speech, Twitter “cannot become a free-for-all hellscape, where anything can be said with no consequences!”  Then he shocked observers (and Twitter employees) by suddenly laying off half the workforce, including much of the content moderation staff. Some are now being asked back, being told they were laid off “by mistake.”   

He then floated a balloon about charging $20 a month for Twitter’s blue verification, had a tweet argument with Stephen King about it, then went forward with a $7.99 plan, only to be punked by users illustrating the flaws.  At this writing, the plan now appears to be on hold, at least until Tuesday’s mid-term elections. 

Advertisers appear to be fleeing, or at least curtailing spending.

As The Wall Street Journal put it: “In Elon Musk’s first week at Twitter Inc., he flouted much of the advice management gurus have dished out for decades.”  It’s no wonder many Twitter users are looking at Mastodon.

Mastodon has been around since 2016, but only recently has seen large increases in users, now up to a million users (versus, it must be noted, Twitter’s 230+ million users).  It was founded by Eugen Rochko, who may be the only actual employee.  He says: “The solution isn't a copy of Twitter without Elon Musk. The solution is a different paradigm of social media.”

The Mastodon paradigm is “decentralized, open source, not for sale, and interoperable.”  It is a collection of “servers” (there are reportedly some 3,000), each run by a different person or organization, with its own moderation policies and focus (e.g., geographic, topic).  Instead of investors, it relies on donations, grants, crowdfunding, sponsorships, and volunteers. 

Users must pick a server to join, some of which (like Mastodon social, the largest) are currently closed or require an invitation. Users can, however, follow users on other servers, although they cannot get as much information about them as ones on the same server.

If it seems like Twitter but more complicated, well, that’s because it is.

Credit: Digital Report

It’s not as though Twitter didn’t need change. It has long had content moderation issues, especially with attacks on women and people of color.  But thar’s par for social media; just look at Facebook. Equally problematic is that it simply has never been consistently profitable.  Layoffs may have been inevitable, as even co-founder and former CEO Jack Dorsey now admits that he may have grown the workforce too rapidly.

Mr. Musk has faced challenges with, and criticism for his actions at, his other companies – Tesla, Space X, Starlink – and yet managed to make each successful, so he may know what he’s doing with Twitter.  Or he may have finally bitten off more than he can chew. 

Of course, not everyone who leaves Twitter is likely to go to Mastodon.  They may opt out of social media, or make more use of established platforms like Facebook, LinkedIn, or Reddit.  Depending on their political views, they might try Truth Social or Tribel. 

Or they wait for Jack Dorsey’s new venture, BlueSky, which purports to be a “decentralized social network” that will foster a “social internet” without data silos.  Some 30,000 people joined its waitlist in the week after Mr. Musk took over Twitter.  The team emphasizes that corporations should not own your online identity, and that users must have control over the algorithms that decide what they see. 

In research done by Casey Fiesler, an information researcher at the University of Colorado, one participant described online migrations as “watching a shopping mall go slowly out of business.”   I.e., there start to be fewer stores or stores of lower quality, so fewer people go, and it becomes a vicious cycle. Twitter may become that dying mall in your community.  Or Myspace (which, to my surprise, still exists).

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When I think about the lessons of twitter for healthcare, the first thing that came to mind was what happens when Judy Faulkner gives up control of Epic?  She’s 79, she’s controlled Epic since its inception, and one has to suspect that her successor will make changes – ones that could threaten (or expand) its dominance.

Or what would happen if Cerner, the #2 EHR, was bought by another opinionated billionaire with big ideas for changing it – oh, wait, Larry Ellison already did that, and he’s not making little plans.

Larry and Elon are texting buddies. Credit: Getty

And I think about how something like 3D printing will revolutionize pharma and the medical device industry.  What about when synthetic biology changes our whole model of healthcare, knowing how to “program biology?  We’re going to see whole healthcare industries collapse.

When I think about Mastodon and BlueSky in particular, I also wonder when/where healthcare’s open source, decentralized solutions will come – and come they will.  Maybe they’ll be DAOs, or maybe a Linux or Wikipedia for healthcare.  The solutions won’t necessarily look like what we’re used to.

So the moral of Elon Musk and Twitter for healthcare is: you may think you are essential to your users.  You may think you can treat them however you want.  But you’re wrong. All you are doing is giving people more reason to leave when they have a choice.      

Mastodons aren’t the only thing that can go extinct.

Rethinking Never Events

It’s a lot more fun to write about exciting new technologies, or companies in other industries that healthcare could learn from, than to pick on healthcare for its many, well-known shortcomings, but there was an article in JAMA Forum last week that I had to note and perhaps expand on: A New Category of “Never Events” – Ending Harmful Hospital Policies, by  Dave A. Chokshi, MD, MSc and Adam L. Beckman, BS (he is also an MD/MBA student). 

The concept of a “Never Event” is well known by this point.  Coined some twenty years ago by Ken Kizer, MD of the National Quality Form (NQF) and soon widely adopted and expanded, it recognizes that healthcare sometimes has egregious errors that shouldn’t happen:  the wrong foot is amputated, the wrong drug/dosage is given, surgical instruments are left inside a patient, and so on.  Organizations like The Leapfrog Group exist largely to try to measure and compare hospitals on such patient safety issues. 

Whoops

Never Events still happen, but hopefully less often.  However, Dr. Chokshi and Mr. Beckman argue that clinical events are not the only ones that should never happen, that there are several other categories that should be included as Never Events. “Hospitals should be places for healing,” the authors say, “not agents of harm—and there is precedent for addressing harm in hospitals. Now, another category of hospital behaviors should be rendered unacceptable—a different set of never events. Five are especially harmful.”

Their list:

1. “Hospitals should never pursue aggressive debt collection tactics against patients who cannot afford their medical bills;
2. A hospital should never spend less on community benefits (such as providing care to uninsured; patients or funding public health programs) than it earns in tax breaks from its nonprofit status
3. Hospitals should never flout federal requirements to be transparent with patients about the costs of their care;
4. Hospitals should never provide compensation worth less than a living for hospital workers;
5. A hospital should never deliver racially segregated medical care, whereby it systematically underserves its surrounding communities of color;”

The authors acknowledge that other healthcare organizations (they mention insurance companies and medical device makers, but could have easily included pharma, dialysis centers, certain physician practices, etc.) are similarly at fault, but felt hospitals deserved particular attention because “the fact that the majority of hospitals are engaged in 1 or more of these 5 behaviors…necessitates attention.” 

I’ve written before about shady hospital billing practices, those faux community benefits, issues with price transparency, inadequate wages for healthcare workers, and inequities in health care, so I feel pretty good about their list.  I hope the article gets the attention it deserves, and that “visionary hospital leaders” and thoughtful policymakers take appropriate action, as the authors call for.  I hope that it doesn’t take another twenty years for these five things to be seen as Never Events. 

But they’re not enough.

I don’t minimize the challenges of ending, or at least lessening those five practices, but I don’t want us to lose sight of other health-related events that we, as a society, should not tolerate.  The complete list is longer than I have room, time, or energy to fully enumerate, but here are some of the ones that should have highest priority:

Hunger: No one in America should go hungry.  Yes, we have SNAP, school lunch programs, and other efforts to make food more affordable/available, but an estimated 34 million people – including 9 million children, are still “food insecure” – never quite sure when or what their next meal might be.

    

Housing: No one in America should go homeless, or live in housing that poses risks to their health.  Estimates for both are tricky, but there is thought to be at least a half million homeless at any point in time, and another 6 million homes (with 16 million living in them) considered severely or moderately substandard housing (some estimates put the number as high as 30 million homes). 

Clean air/water: No one in America should lack clean water/air. We like to think we live in a developed country, but some 2 million people are estimated to lack clean water (and sanitation); think Jackson (MS) or Flint (MI). Even more shocking, 135 million Americans are forced to breath polluted air.   

Hiding errors: No one in America should be subject to medical errors that could have been prevented. How many medical errors are there?  Who is committing them, and why (e.g., incompetence versus situational)?  We don’t know.  Due to concerns about medical malpractice, professional autonomy, and other factors, we don’t have solid mechanisms to report errors, analyze and act on them, or to ensure that problematic healthcare professionals either get better or get out the profession.

Ineffective/harmful care: No one in America should receive care that is unlikely to actually help them. We don’t like to admit it, but most of the care we receive is not based on solid research. We don’t like to admit it, but even when such research is available, it may take years, if ever, for practitioners to adopt it.  Too much care is based on “this is how I was trained” (whenever, wherever that was) or “this is how others around me practice” (whomever, wherever that is).  “How much will I make from this?” also plays too much of a factor.

Limiting care: No one in America should be prevented from receiving care they need. “Rationing” healthcare is universally denounced by politicians, but anyone working in healthcare or receiving healthcare knows it happens all the time. It happens when people can’t afford it, it happens when tests or procedures are denied, it happens when patients are forced to only use network providers.  Not all care is appropriate (as noted above), more care isn’t always (or even usually) better, and some healthcare professionals cause harm, but here’s the thing -- the goal of everyone in healthcare should be: how do I help get this patient to the right person/place for the right kind of treatment? 

Credit: Glow Wellness/Getty Images

All of these should be Never Events in a civilized society and in a healthcare system that we’re proud of.  Sadly, they’re not, and I’ll bet that Dr. Chockshi and Mr. Beckman see their list accomplished before I see mine.  But that doesn’t mean we shouldn’t be working on both. 

Kudos to Dr. Chokshi and Mr. Beckman for broadening the issue, and it’s on all of us to make Never Events – of all kinds -- never happen.

Art Is in the Eye of the Computer

It turns out that I’ve been writing about Generative AI without even realizing there was something called Generative AI, such as articles about the robot artist Ai-Da, the AI image creator DALL-E, or patent protection for AI inventors.  Generative AI refers to AI that strives not just to process and synthesize data but to actually be creative.  It’s starting to both become more widespread and to attract serious attention from investors. 

Credit: AWP Life

James Currier of investment firm NFX sees “Generative Tech” as the next big thing: “If crypto hadn’t happened, we’d probably be calling THIS Web3.”  He distinguishes Generative AI from Generative Tech as:

Some have called it “Generative AI,” but AI is only half of the equation. AI models are the enabling base layers of the stack. The top layers will be thousands of applications. Generative Tech is about what will actually touch us – what you can do with AI as a partner.

He predicts Generative Tech will generate “trillions of dollars of value.”  I’m hoping that healthcare is paying attention.

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Let’s start with OpenAI and its DALL-E 2.  DALL-E 2 got much attention earlier in the year with its startlingly unique images, and now is more broadly available, with more than 1.5 million users.  The Wall Street Journal calls its images “amazing – and terrifying.” 

OpenAI is overseen by a non-profit company, and its mission is “to ensure that artificial general intelligence benefits all humanity,” presumably meant to draw the distinction from AI developed by for-profit companies (such as DeepMind, which is owned by Alphabet).  Its charter explicitly states that it seeks that AI/AGI “is used for the benefit of all, and to avoid enabling uses of AI or AGI that harm humanity or unduly concentrate power.”  Its “primary fiduciary duty is to humanity.”

Credit: OpenAI

Microsoft invested $1b in 2019 (in return for OpenAI using Azure as its cloud partner and giving Microsoft priority in brining new technologies to market), and The Wall Street Journal now reports that the companies are in “advanced talks” for a new round of funding. OpenAI is valued at nearly $20b.

Then there’s Stability AI, which just announced a $101 million funding round that values the company at $1b. It bills itself as “the world's first community-driven, open-source artificial intelligence (AI) company,” with a slogan “AI by the people, for the people.”  Emad Mostaque, founder and CEO, states:

Stability AI puts the power back into the hands of developer communities and opens the door for ground-breaking new applications. An independent entity in this space supporting these communities can create real value and change.

Its competitors to DALL-E are Stable Diffusion, released in August, “a powerful, free and open-source text-to-image generator” that already has been licensed by 200,000 developers, and DreamStudio, its consumer-facing image product that has a million registered users. 

A New York Times article noted that Stable Diffusion has limited safety filters, which has made it popular among artists and has led to some, shall we say, objectionable images.  Mr. Mostaque is undeterred, telling the NYT: “We trust people, and we trust the community, as opposed to having a centralized, unelected entity controlling the most powerful technology in the world.” 

He made a similar point to TechCrunch: “Nobody has any voting rights except our employees — no billionaires, big funds, governments or anyone else with control of the company or the communities we support. We’re completely independent.” 

Credit: Stability AI

Still another Generative AI company, Jasper, also scored a funding round last week, with the $125 million round valuing it at $1.5b.  Jasper bills itself as an “AI Content Platform,” including both generating text and text-to-images.  Interestingly, it uses OpenAI’s GPT-3 to power the platform. 

Jasper CEO Dave Rogenmoser says: “Generative AI represents a major breakthrough in creative potential, but it's still inaccessible and intimidating to many. Jasper is working to bring AI to the masses and teach people how to leverage it responsibly so that businesses and individuals can better convey their ideas.” 

I’d be remiss if I didn’t at least mention Anthropic, which has raised close to $800 million, or MidJourney, which boosts 3 million users taking advantage of image generator on its Discord server.  Anthropic is set up as a public benefit corporation, and is “working to build reliable, interpretable, and steerable AI systems,” while MidJourney describes itself as “a small self-funded team focused on design, human infrastructure, and AI.”  I’m sure there are others.

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Joanna Stern, writing in the WSJ, marvels: “The stuff once found in AI research labs is now making it into our homes and offices…For decades, we’ve been hearing AI is going to change how we interact with computers and the world. These tools may be the first time most of us recognize it in action.”

There’s already much concern about the “black box” of AI – we may not know how or why AI comes up with things – and the implicit biases that may be built it (e.g., most healthcare data sets will include the results of the inequities in our current healthcare system).  Stability AI’s Mr. Mostaque told NYT: “Ultimately, transparency, not top-down control, is what will keep generative A.I. from becoming a dangerous force,” and I hope he’s right – but I’m not sure he is.

I love the idea of “democratizing” AI, putting it in our homes and offices.  I like the idea that some of this is happening through non-profits, like OpenAI.  I’m highly intrigued that some of it is open source, like Stability AI.  And I’m wondering what the impetus in healthcare will be to bring it to our care and to our daily lives.

Credit: Pixabay

If Mr. Currier is remotely right that Generative Tech will unleash trillions of dollars in value, healthcare is not going to be untouched.  I’d love to see a collection of our healthcare giants – health systems, health plans, pharma, etc. – pool their data for use by a non-profit focused on AI for healthcare.  I’d like that AI not just be better supportive tools for clinicians, but also to be creative, up to and including “AI physicians,” whatever they may be.  And I think it’d be cool if much of this work could be open source and aimed at the masses.    

Mr. Currier predicts: “In the next 10 years, we will expect software to collaborate with us. It will be the new normal. Steve Jobs said in 1980 that the Apple personal computer was a bicycle for the human mind. You might say that Generative Tech is a rocketship for the human mind.” 

Buckle up: it’s going to be a bumpy ride. 

Sticks and Stones...

According to the old saying, sticks and stones may break your bones, but names can never hurt you.  I’m not sure that still applies in a social media environment that can have real impacts on mental health of both teenagers and adults, but I have to note that healthcare seems to be pretty sensitive about who calls whom what. 

I’ll start with a new study from The Mayo Clinic about whether patients addressed their physicians by their first name.  It’s a tricky thing to get a gauge on; one could do surveys of both populations, or implant observers in exam rooms, but these researchers had the clever idea of examining how patients addressed their physician when using portal messaging.  They looked at over 90,000 messages from nearly 15,000 patients, with about 30,000 messages from 15,000 patients including a physician’s name (first or last).

The researchers don’t seem to have provided an overall percent of patients using the doctors’ first name, but they did report:

• Female doctors were twice as likely as male doctors to be called by their first name;
• DOs were similarly almost twice as likely as MDs to have their first name used;
• Primary care doctors were 50% more likely than specialists;
• Female patients were 40% less likely to use first names when addressing their physician.

The authors noted that they don’t know if physicians had expressed preferences about how they should be addressed, but warned:

The pattern of addressing physicians with different titles based on gender, degree, and specialty may be forms of bias…Whether being informally addressed by other medical professionals or patients, untitling (not using a person’s proper title) may have a negative impact on physicians, demonstrate lack of respect, and can lead to reduction in formality of the physician-patient relationship or workplace.

In a New York Times article about the study, Debra Roter, an emeritus professor of health, behavior and society at Johns Hopkins’ Bloomberg School of Public Health, said: “Doctors might find it [patients using first names] is undermining their authority.  There’s a familiarity that first names gives people.”  However, doctors calling patients by their first name also carries risks, she acknowledged: “It could infantilize the patient or establish the paternalism of the doctor.”

Similarly, in an accompanying commentary, two female physicians (who were not involved in the research) state: “Use of formal titles in medicine and many other professions is a linguistic signal of respect and professionalism,” although they also add: “Such respect in professional communication should be bidirectional, as medical students learn early in training to ask patients how they prefer to be called during medical encounters.”

Most of my physicians must have missed those classes. 

I’ll note that pharmacists these days have PharmD’s, and physical therapists have DPTs, but few of us have qualms about addressing them by their first name.  Lawyers have a JD, but don’t usually insist on being addressed by the title.  University professors and judges are the only two other professions I can think of with expectations about being called by their title instead of their name.  Make of that what you will. 

I don’t know what most physicians prefer to be called, but I know what they hate to be called: providers. I don’t know how many op-ed pieces, tweets, LinkedIn posts, etc. I’ve seen over the years in which physicians complain about the practice.  It’s been associated with how the Nazis minimalized Jewish physicians in 1930’s Germany, called “a powerful tool to confuse and dehumanize a physician,” and led to warnings that “the adaptation of this terminology led to medicine being thought of only as a business, a commoditization of care.” 

Using “provider” to describe physicians, physicians say, disrespects them, understates their years of training, confuses patients, causes “moral injury” to physicians, and may lead, or at least contribute to, physician burnout.  A rose by any other name might still smell as sweet, but a doctor by that term is, apparently, catastrophic.   

I have a pretty good guess as to how physicians who object to being referred to as a provider probably feel about being called by their first name.

While we’re being sensitive, some of us have an issue with being referred to as a patient.  I’ve written before that use of the term is a design problem.  It’s an implicit expectation that we should literally be patient (think of all that time we are expected to just wait), and trust in the greater expertise of physicians; as Dr. Roter noted, it infantilizes the patient and perpetuates the paternalism in the physician/patient relationship.  Moreover, it ignores our existence outside the healthcare system, failing to acknowledge that we have lives outside of it and how those lives impact our health.

As Matthew Zachery recently wrote about the practice, “We are no longer people.”  He goes on to elaborate:

We are products on a shelf, numbers on a page, ink stains on a fax transmission, and zeroes and ones existing only in data centers polluting the earth with their carbon footprints. Patients today are loss-leading, actuary-derived, health-economic meat on a stick.

And to think that some physicians believe that it is using “provider” which led to the commercialization of health care.

Mr. Zachery prefers the term “consumer,” as does my friend Jane Sarasohn-Kahn, but I have to admit that I don’t like that term much better.  We don’t do much intelligent shopping in health care: we don’t really have the right tools, not much in the system is oriented towards encouraging us to try, and there are too many health episodes when we have neither the time nor inclination to consume wisely. 

The bigger problem, as I’ve also written about before, is that, forget healthcare: we’re not really very good consumers of anything.  The concept of a “rational consumer” is a “myth,” says psychologist Peter Noel Murray.  We’re swayed by too many superficial factors that often bear little relevance to quality or value, whether that is healthcare, mobile phones, or automobiles.    

Patients as patients, consumers, or what?

So here’s where I come down: to all the people working in healthcare, or those using healthcare services, who have issues with what they are called: get over it. If that’s the problem in healthcare you are focused on, you are focusing on the wrong problem.  Healthcare has much bigger problems, that need more immediate solutions, and I hate that anyone is spending any extra time or emotional energy on this particular issue.

Treat people with respect; treat them as individuals, whether they are doctors, people receiving services, the person cleaning up, or anyone else.

Better Living Through Better Design

We’re almost two weeks past Hurricane Ian. Most of us weren’t in its path and so it just becomes another disaster that happened to other people, but to those people most impacted it is an ongoing challenge: over a hundred people dead, hundreds of thousands still without power, tens of thousands facing a housing crisis due to destroyed/damaged homes, and estimated $67b in damages.  It will take years of rebuilding to recover. 

Credit: International Union of Architects

In the wake of a natural disaster like a hurricane – or a tornado, a flood, even a pandemic – it’s easy to shrug our shoulders and say, well, it’s Mother Nature, what can we do?  There’s some truth to that, but the fact is there are choices -- design choices -- we can make to mitigate the impacts. A Florida community called Babcock Ranch helps illustrate that.

Babcock Ranch is located a few miles inland from Ft. Myers, which was devastated by Ian.  It bills itself as “America’s first solar-powered town,” with an impressive array of almost 700,000 solar panels. More than that, it was built with natural disasters in mind: all utilities are underground, it makes use of natural landscaping to help contain storm surges, streets are designed to divert floodwaters, making use of multiple retaining ponds.

Credit: Babcock Ranch

It survived Ian with no loss of power, no flooding, and no major damage.  Its community center is serving as a refuge for people from communities that were not as fortunate. A spokesperson for Syd Kitson, the man behind the development, told CNN: “It’s a great case study to show that it can be done right, if you build in the right place and do it the right way,”

Mr. Kitson told 60 Minutes: “So as soon as the sun came up the next morning, I jumped in my car and I started driving out. And the only damage were a few down trees and a few shingles off the roofs. That's it. And so our recovery was maybe a day.”

Good luck, or good design?  As NPR said about one Babcock Ranch family whose home escaped damage: “But it wasn't just luck that saved Wilkerson and his wife, Rhonda, or prevented damage to their well-appointed one-story house. You might say that it was all by design.”

The project was begun in 2015, with first residents moving in in 2018.  It currently has some 2,000 homes – ranging from condos to starter homes to estate houses – and 5,000 residents (which Mr. Kitson expects will grow to 50,000).

Jennifer Languell, a sustainability engineer who helped design the project and now lives there, told NPR:

We felt you could develop and improve land, not just develop in a traditional way where people think you are destroying the land.

The things that we do, you don't see. The strength of the buildings, or the infrastructure that deals with stormwater, or the utilities. You don't see that stuff.  Which is good, because most people don't need or want to think about it.

One could argue, well, Babcock Ranch was further inland, it had more recent construction with more stringent building codes, it didn’t have mobile homes, it wasn’t built in floodplains.  To which I’d argue: Those. Are. Design. Decisions. 

Babcock Ranch was designed not just to withstand hurricanes but also:

…to offer residents multiple ways to improve their physical and mental wellbeing. From the Lee Health Healthy Life Center, to carefully planned greenspaces and nature trails, to our robust resident programming, there are countless ways to get active, expand your social circle, and build a life that positively shapes your overall wellbeing.

It’s all about design, about the choices we make…or don’t think to make.

As hurricane damage goes, not so bad Credit: Nancy Chorpenning/CNN

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I’ve been thinking about the role of design in health since I was fortunate enough to get to know Steve Downs, then at Robert Wood Johnson Foundation and now at Building H. Back in 2017 he wrote about how it was important to “build health into the OS of our daily lives.” As the Building H website warns:

Modern life is great at making us happy – in the short term.

In the long term, it’s killing us. By design.

 

From cheap calories to free freeways, from second cars to second refrigerators, our everyday environment is engineered for convemience, passivity, and gratification.

The result: An epidemic of obesity & diabetes, depression & chronic pain.

 

And if you’re thinking healthcare can solve this…you’re already too late.

To this point, The New York Times recently reported about how trying to contain the epidemic of diabetes through medical care is doomed to failure.  In words Steve would agree with, Dr. Dean Schillinger, a professor of medicine at UCSF, told NYT: “Our entire society is perfectly designed to create Type 2 diabetes. We have to disrupt that.”

The article further asserts:

There is no device, no drug powerful enough to counter the effects of poverty, pollution, stress, a broken food system, cities that are hard to navigate on foot and inequitable access to health care, particularly in minority communities.

Dr. Schillinger was one of numerous experts who was part of the National Clinical Care Commission, which issued a report earlier this year urging Congress to put more focus on the social and environmental factors that contribute to diabetes and make managing it more difficult. They called for a “health-in-all-policies” approach, whether those are health, housing, nutrition, or environmental policies.

Credit: National Clinical Care Commission

As Dr. Schillinger told NYT:

It’s about massive federal subsidies that support producing ingredients that go into low-cost, energy-dense, ultra-processed and sugar-loaded foods, the unfettered marketing of junk food to children, suburban sprawl that demands driving over walking or biking — all the forces in the environment that some of us have the resources to buffer ourselves against, but people with low incomes don’t.

Steve would urge that this approach should not just apply to diabetes.   

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Babcock Ranch isn’t Utopia.  I doubt there aren’t many low income people there. I suspect it doesn’t have many people of color. I’d be interested to know what happens to its sewage and trash. Its residents probably still drive too much, eat too much (of the wrong foods), and get too much medical care.  It may have survived Ian very well, but it is still in Florida, where there will always be another hurricane, which might prove more damaging.

But still.  Babcock Ranch is an example that design can make a difference in our lives, in our safety, and in our health.  Let’s hope it doesn’t take too many more disasters for us to learn that lesson.