Batteries All Around

Quick question: how many batteries do you have? Chances are, the answer is way bigger than you think. They’re in your devices (e.g., smartphones, tablets, laptops, ear buds), they’re throughout your house (e.g., clocks, smoke detectors), they’re in your car (even if you don’t have an EV), and they may even be in you. We usually only think about them when they need recharging, or when they catch fire. They can be an environmental nightmare if not recycled, and recycling lithium-ion batteries is still problematic.  

This should not be our future. Credit: Bing Image Creator

So I was intrigued to read about some efforts to rethink what a battery is.

Let’s start with some work done by Swedish tech company Sinonus, a spinout of Chalmers University of Technology and KTH Royal Institute of Technology. The company is all about carbon fiber; more specifically, integrating structural strength and storing energy.

It seeks to make things multipurpose: “Just think of your smartphone, today it seems farfetched to use a single purpose phone, camera and mp3 player when you can have them all in one. In the same way we can transform single purpose materials, such as structure materials and batteries, through our multipurpose carbon fiber composite solution.” 

Or, as TechRadar put it, “how the laptop could become the battery.”

Sinonus says its carbon fiber based composite “can provide structural strength and store energy, all in one. By doing so we can utilize the mass that is "already there" to store energy, creating an opportunity to reduce weight, volume and improve overall system performance.”

Carbon fiber battery. Credit: Sinonus

New Atlas raves:

Imagine an electric car that isn't weighed down by a huge, kilowatt-hour-stuffed battery. It wouldn't need as much power to drive it forward and could rely on a smaller motor, saving yet more weight. Or imagine an eVTOL that could take off without lifting a lithium-ion anchor that requires it to be back on the ground within an hour for charging. Or a windmill with blades that work as their own batteries, storing energy during low demand periods for distribution at peak hours.

CEO Markus Zetterström explains: “Storing electrical energy in carbon fiber may perhaps not become as efficient as traditional batteries, but since our carbon fiber solution also has a structural load-bearing capability, very large gains can be made at a system level.” That reduced efficiency may be a cause for concern, but, as Jeff Butts wrote in Tom’s Hardware: “After all, if your laptop is smaller and lighter while still giving the same battery life, it hardly matters that the material storing the energy isn’t as efficient as a LiON battery pack.”

It has already replaced AAA batteries in low-power lab tests, but still has some considerable way to go to achieve more power and to make the materials cost-effective. Still, it cites a Chambers study that suggested this approach could increase EV range by 70%, while eliminating volatile chemicals that create the landfill issues and the potential for fires. 

According to Recharge News, Sinonus is also looking to use the carbon fiber in wind turbine blades, so they could act as their storage device as well.  It is also considering using its composite in the “internal fabric” of buildings.

Speaking of which, if you like the idea of your laptop chassis acting as its own battery, you should love this: how about your house being its own battery?

Work done at MIT, led by Dr. Damian Stefaniuk, has created a way to store power in a form of concrete made from cement, water, and something called carbon black. It technically forms a supercapacitor, not a battery, but it can store energy. BBC’s Tom Ough writes that supercapacitors are very efficient in storing energy, charge more rapidly than lithium-ion batteries, but also release their energy more rapidly, something that the team is working on.

The first time the team connected an LED to a piece of the concrete, it lit up. "At first I didn't believe it," said Dr. Stefaniuk. "I thought that I hadn't disconnected the external power source, and that was why the LED was on. It was a wonderful day."

Dr. Stefaniuk and his team describe roads that collect and store solar energy, charging EV vehicles as they drive on them. Or – and the folks at Sinonus should love this – as part of a building’s structure: “to have walls, or foundations, or columns, that are active not only in supporting a structure, but also in that energy is stored inside them."

As Dr. Stefaniuk told BBC: “A simple example would be an off-grid house powered by solar panels: using solar energy directly during the day and the energy stored in, for example, the foundations during the night."

Credit: MIT/Damian Stefaniuk

The team still has a long way to go in terms of how much power the material can produce, and, whoops, the addition of the carbon black makes the concrete weaker, so there is still work to be done in fine-tuning the ideal mixture. It should also be noted that production of cement is not without its own environmental impact.

But, as Michael Short, head of the Centre for Sustainable Engineering at Teesside University, told BBC: “As the materials are also commonplace and the manufacture relatively straightforward, this gives a great indication that this approach should be investigated further and could potentially be a very useful part of the transition to a cleaner, more sustainable future."

And if those two examples aren’t quite ready, the next wave for batteries may be sodium-ion, instead of lithium-ion, with the advantage that sodium is much more common than lithium. China already has a large scale battery storage system, and, in the U.S., Natron Energy has just launched its commercial scale operations. Colin Wessells, founder and co-CEO, Natron Energy, said: “The electrification of our economy is dependent on the development and production of new, innovative energy storage solutions. We at Natron are proud to deliver such a battery without the use of conflict minerals or materials with questionable environmental impacts.”

I love reducing our dependence on rare materials like lithium, replacing it with more common materials like carbon or sodium. But I especially like making our energy technology part of our everyday structures, much as the Internet-of-Things (IoT) has long promised about our computing. As Sinonus strives for, making single purpose solutions multipurpose.

As various people have said in various ways, the best technology should be invisible.   

Innovators: Avoid Healthcare

NVIDIA founder and CEO Jensen Huang has become quite the media darling lately, due to NVIDIA’s skyrocketing market value the past two years ($3.3 trillion now, thank you very much. A year ago it first hit $1 trillion). His company is now the world’s third largest company by market capitalization. Last week he gave the commencement speech at Caltech, and offered those graduates some interesting insights.

Jensen Huang at Caltech. Credit: NVIDIA

Which, of course, I’ll try to apply to healthcare.

Mr. Jensen founded NVIDIA in 1993, and took the company public in 1999, but for much of its existence it struggled to find its niche. Mr. Huang figured NVIDIA needed to go to a market where there were no customers yet – “because where there are no customers, there are no competitors.” He likes to call this “zero billion dollar markets” (a phrase I gather he did not invent).

About a decade ago the company bet on deep learning and A.I. “No one knew how far deep learning could scale, and if we didn’t build it, we’d never know,” Mr. Huang told the graduates. “Our logic is: If we don’t build it, they can’t come.”

NVIDIA did build it, and, boy, they did come.

Credit: NVIDIA

He believes we all should try to do things that haven’t been done before, things that “are insanely hard to do,” because if you succeed you can make a real contribution to the world.  Going into zero billion dollar markets allows a company to be a “market maker, not a market-taker.” He’s not interested in market share; he’s interested in developing new markets.

Accordingly, he told the Caltech graduates:

I hope you believe in something. Something unconventional, something unexplored. But let it be informed, and let it be reasoned, and dedicate yourself to making that happen. You may find your GPU. You may find your CUDA. You may find your generative AI. You may find your NVIDIA.

And in that group, some may very well.

He didn’t promise it would be easy, citing his company’s own experience, and stressing the need for resilience. “One setback after another, we shook it off and skated to the next opportunity. Each time, we gain skills and strengthen our character,” Mr. Huang said. “No setback that comes our way doesn’t look like an opportunity these days… The world can be unfair and deal you with tough cards. Swiftly shake it off. There’s another opportunity out there — or create one.”

He was quite pleased with the Taylor Swift reference; the crowd seemed somewhat less impressed.

Some of those graduates will probably end up working on artificial intelligence, perhaps at NVIDIA (he announced at the beginning that he was recruiting). Others will get snapped up by other Big Tech companies. More than a few will start their own companies. And a fair number will probably end up working on healthcare, in one way or another.

Healthcare needs bright people. It needs innovation; lots of it. It needs to be more efficient, and, hopefully, more effective. There’s no shortage of new ideas or money for them; according to Silicon Bank, venture capital firms poured $19b into healthcare in 2023, after $50b for 2021-22. It is already incorporating A.I. faster than I might have predicted, such as in drug development, where it is said to be “revolutionizing” the field. A.I. is also rapidly starting to “copilot” doctors.

But, I fear, these all seem like market-takers, not market makers.

Ten years ago I wrote Getting Our Piece of the Pie, expressing my concern that healthcare innovators were more interested in getting their share of the nation’s then $3 trillion spending (it’s now $5 trillion). “We need innovators who don't want a slice of the existing pie,” I wrote, “but are willing to throw it away and make a new kind of pie.”

I think Mr. Huang would agree.

The internet should have transformed healthcare. Electronic health records should have transformed healthcare. Digital health should have transformed healthcare. But they didn’t. Sure, they changed healthcare, but healthcare first tried to ignore them, but then simply absorbed them in its big bear hug. “OK,” it said. “We can use you, but don’t expect anything to be cheaper or smaller, and don’t expect any of the major players to go away.” Now it’s doing the same with A.I.

Everywhere you look in healthcare, there are competitors. To be more accurate, everywhere you look there are consolidators, because many parts of our healthcare system prefer to dominate markets than to compete in them (e.g., Epic, UHC, and many local health systems). But an innovator would be hard pressed to find a market niche without competition. And the thought of doing something where there are no customers is anathema to most healthcare innovators.

Honestly, I think healthcare innovators who start building things thinking about patients, doctors, hospitals, pharma/PBMs, and health insurance companies, well – I don’t think they should bother. That paradigm is hitting a dead end. We need new paradigms.

When imaginary numbers were developed during the Renaissance, no one expected that they’d be useful for anything, much less than they’d be integral (pun intended) for electrical engineering and quantum mechanics. Neither of those fields even existed yet. Alexander Graham Bell was more interested in helping the deaf than in inventing the telephone. And Bob Taylor of ARPA (now DARPA) didn’t expect to create the internet when it came up with ARPANET.

Big, bold ideas find – create -- their own markets.

If you want to make a mark in healthcare, look for the zero billion dollar markets. Look for the things that customers haven’t yet realized they have a need for. Look for the things that no competitor is interested in (or hasn’t thought of). Look to build things with the logic: “If we don’t build it, they can’t come.” Look to change the world, not just to make healthcare a little less bad.

If you do all that, or some of that, perhaps health or healthcare will benefit as well, even if it’s not what we think of it as “health” or “healthcare” now.  Find your own NVIDIA.

Oh. Never Mind

You may have read the coverage of last week’s tar-and-feathering of Dr. Anthony Fauci in a hearing of the House Select Subcommittee on the Coronavirus Pandemic. You know, the one where Majorie Taylor Greene refused to call him “Dr.”, told him: “You belong in prison,” and accused him – I kid you not – of killing beagles. Yeah, that one.

Congressional hearings aren't the best way to find the truth. Credit: BBC

Amidst all that drama, there were a few genuinely concerning findings. For example, some of Dr. Fauci’s aides appeared to sometimes use personal email accounts to avoid potential FOIA requests. It also turns out that Dr. Fauci and others did take the lab leak theory seriously, despite many public denunciations of that as a conspiracy theory. And, most breathtaking of all, Dr. Fauci admitted that the 6 feet distancing rule “sort of just appeared,” perhaps from the CDC and evidently not backed by any actual evidence.

I’m not intending to pick on Dr. Fauci, who I think has been a dedicated public servant and possibly a hero. But it does appear that we sort of fumbled our way through the pandemic, and that truth was often one of its victims.

In The New York Times,  Zeynep Tufekci minces no words:

I wish I could say these were all just examples of the science evolving in real time, but they actually demonstrate obstinacy, arrogance and cowardice. Instead of circling the wagons, these officials should have been responsibly and transparently informing the public to the best of their knowledge and abilities.

As she goes on to say: “If the government misled people about how Covid is transmitted, why would Americans believe what it says about vaccines or bird flu or H.I.V.? How should people distinguish between wild conspiracy theories and actual conspiracies?”

Credit: Menninger

Indeed, we may now be facing a bird flu outbreak, and our COVID lessons, or lack thereof, could be crucial. There have already been three known cases that have crossed over from cows to humans, but, like the early days of COVID, we’re not actively testing or tracking cases (although we are doing some wastewater tracking). “No animal or public health expert thinks that we are doing enough surveillance,” Keith Poulsen, DVM, PhD, director of the Wisconsin Veterinary Diagnostic Laboratory at the University of Wisconsin-Madison, said in an email to Jennifer Abbasi of JAMA.

Echoing Professor Tufekci’s concerns about mistrust, Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told Katherine Wu of The Atlantic his concerns about a potential bird flu outbreak: “without a doubt, I think we’re less prepared.” He specifically cited vaccine reluctance as an example.

Sara Gorman, Scott C. Ratzan, and Kenneth H. Rabin wondered, in StatNews, if the government has learned anything from COVID communications failures: in regards to a potential bird flu outbreak,  “…we think that the federal government is once again failing to follow best practices when it comes to communicating transparently about an uncertain, potentially high-risk situation.” They suggest full disclosure: “This means our federal agencies must communicate what they don't know as clearly as what they do know.”

But that runs contrary to what Professor Tufekci says was her big takeaway from our COVID response: “High-level officials were afraid to tell the truth — or just to admit that they didn’t have all the answers — lest they spook the public.”

A new study highlights just how little we really knew. Eran Bendavid (Stanford) and Chirag Patel (Harvard) ran 100,000 models of various government interventions for COVID, such as closing schools or limiting gatherings. The result: “In summary, we find no patterns in the overall set of models that suggests a clear relationship between COVID-19 government responses and outcomes. Strong claims about government responses’ impacts on COVID-19 may lack empirical support.”

In an article in Stat News, they elaborate: “About half the time, government policies were followed by better Covid-19 outcomes, and half of the time they were not. The findings were sometimes contradictory, with some policies appearing helpful when tested one way, and the same policy appearing harmful when tested another way.”

They caution that it’s not “broadly true” that government responses made things worse or were simply ineffective, nor that they demonstrably helped either, but: “What is true is that there is no strong evidence to support claims about the impacts of the policies, one way or the other.”

Fifty-fifty.  All those policies, all those recommendations, all the turmoil, and it turns out we might as well just flipped a coin.

Like Professor Tufekci, Dr. Gorman and colleagues, and Ms. Wu, they urge more honesty: “We believe that having greater willingness to say “We’re not sure” will help regain trust in science.”  Professor Zufekci quotes Congresswoman Deborah Ross (D-NC): “When people don’t trust scientists, they don’t trust the science.” Right now, there’s a lot of people who neither trust the science or the scientists, and it’s hard to blame them.

Professor Zufekci laments: “As the expression goes, trust is built in drops and lost in buckets, and this bucket is going to take a very long time to refill.” We may not have that kind of time before the next crisis.

Professors Bendavid and Patel suggest more and better data collection for critical health measures, on which the U.S. has an abysmal record (case in point: bird flu), and more experimentation of public health policies, which they admit “may be ethically thorny and often impractical” (but, they point out, “subjecting millions of people to untested policies without strong scientific support for their benefits is also ethically charged”).  

As I wrote about last November, American’s trust in science is declining, with the Pew Research Center confirming that the pandemic was a key turning point in that decline. Professors Bendavid and Patel urge: “Matching the strength of claims to the strength of the evidence may increase the sense that the scientific community’s primary allegiance is to the pursuit of truth above all else,” but in a crisis – as we were in 2020 – there may not be much, if any, evidence available but yet we still are desperate for solutions.

We all need to acknowledge that there are experts who know more about their fields than we do, and stop trying to second guess or undermine them. But, in turn, those experts need to be open about what they know, what they can prove, and what they’re still not certain about. We all failed those tests in 2020-21, but, unfortunately, we’re going to get retested at some point, and that may be sooner rather than later.

Who Needs Humans, Anyway?

Imagine my excitement when I saw the headline: “Robot doctors at world’s first AI hospital can treat 3,000 a day.” Finally, I thought – now we’re getting somewhere. I must admit that my enthusiasm was somewhat tempered to find that the patients were virtual. But, still.

Are they human or AI? Credit: Bing Image Creator

The article was in Interesting Engineering, and it largely covered the source story in Global Times, which interviewed the research team leader Yang Liu, a professor at China’s Tsinghua University, where he is executive dean of Institute for AI Industry Research (AIR) and associate dean of the Department of Computer Science and Technology. The professor and his team just published a paper detailing their efforts.  

The paper describes what they did: “we introduce a simulacrum of hospital called Agent Hospital that simulates the entire process of treating illness. All patients, nurses, and doctors are autonomous agents powered by large language models (LLMs).” They modestly note: “To the best of our knowledge, this is the first simulacrum of hospital, which comprehensively reflects the entire medical process with excellent scalability, making it a valuable platform for the study of medical LLMs/agents.”

In essence, “Resident Agents” randomly contract a disease, seek care at the Agent Hospital, where they are triaged and treated by Medical Professional Agents, who include 14 doctors and 4 nurses (that’s how you can tell this is only a simulacrum; in the real world, you’d be lucky to have 4 doctors and 14 nurses). The goal “is to enable a doctor agent to learn how to treat illness within the simulacrum.”

Overview of the AI hospital. Credit: Li, et. alia

The Agent Hospital has been compared to the AI town developed at Stanford last year, which had 25 virtual residents living and socializing with each other. “We’ve demonstrated the ability to create general computational agents that can behave like humans in an open setting,” said Joon Sung Park, one of the creators. The Tsinghua researchers have created a “hospital town.”

Gosh, a healthcare system with no humans involved. It can’t be any worse than the human one. Then, again, let me know when the researchers include AI insurance company agents in the simulacrum; I want to see what bickering ensues.

As you might guess, the idea is that the AI doctors – I’m not sure where the “robot” is supposed to come in – learn by treating the virtual patients. As the paper describes: “As the simulacrum can simulate disease onset and progression based on knowledge bases and LLMs, doctor agents can keep accumulating experience from both successful and unsuccessful cases.”

Credit: Li, et. alia

The researchers did confirm that the AI doctors’ performance consistently improved over time. “More interestingly,” the researchers declare, “the knowledge the doctor agents have acquired in Agent Hospital is applicable to real-world medicare benchmarks. After treating around ten thousand patients (real-world doctors may take over two years), the evolved doctor agent achieves a state-of-the-art accuracy of 93.06% on a subset of the MedQA dataset that covers major respiratory diseases.”

The researchers note the “self-evolution” of the agents, which they believe “demonstrates a new way for agent evolution in simulation environments, where agents can improve their skills without human intervention.”  It does not require manually labeled data, unlike some LLMs. As a result, they say that design of Agent Hospital “allows for extensive customization and adjustment, enabling researchers to test a variety of scenarios and interactions within the healthcare domain.”

The researchers’ plans for the future include expanding the range of diseases, adding more departments to the Agent Hospital, and “society simulation aspects of agents” (I just hope they don’t use Grey’s Anatomy for that part of the model).  Dr. Liu told Global Times that the Agent Hospital should be ready for practical application in the 2^nd half of 2024.

One potential use, Dr. Liu told Global Times, is training human doctors:

…this innovative concept allows for virtual patients to be treated by real doctors, providing medical students with enhanced training opportunities. By simulating a variety of AI patients, medical students can confidently propose treatment plans without the fear of causing harm to real patients due to decision-making error. 

No more interns fumbling with actual patients, risking their lives to help train those young doctors. So one hopes.

AI hospital research team. Credit: Liu via Global Times

I’m all in favor of using such AI models to help train medical professionals, but I’m a lot more interested in using them to help with real world health care. I’d like those AI doctors evaluating our AI twins, trying hundreds or thousands of options on them in order to produce the best recommendations for the actual us. I’d like those AI doctors looking at real-life patient information and making recommendations to our real life doctors, who need to get over their skepticism and use AI input as not only credible but also valuable, even essential.

There is already evidence that AI-provided diagnoses compare very well to those from human clinicians, and AI is only going to get better. The harder question may be not in getting AI to be ready than in – you guessed it! – getting physicians to be ready for it. Recent studies by both Medscape and the AMA indicate that the majority of physicians see the potential value of  AI in patient care, but were not ready to use it themselves.

Perhaps we need a simulacrum of human doctors learning to use AI doctors.

In the Global Times interview, the Tsinghua researchers were careful to stress that they don’t see a future without human involvement, but, rather, one with AI-human collaboration.  One of them went so far as to praise medicine as “a science of love and an art of warmth,” unlike “cold” AI healthcare.

Yeah, I’ve been hearing those concerns for years. We say we want our clinicians to be comforting, displaying warmth and empathy. But, in the first place, while AI may not yet actually be empathetic, it may be able to fake it; there are studies that suggest that patients overwhelmingly found AI chatbot responses more empathetic than those from actual doctors.

In the second place, what we want most from our clinicians is to help us stay healthy, or to get better when we’re not. If AI can do that better than humans, well, physicians’ jobs are no more guaranteed than any other jobs in an AI era.

But I’m getting ahead of myself; for now, let’s just appreciate the Agent Hospital simulacrum.

Your Water, or Your Life

Matthew Holt, publisher of The Health Care Blog, thinks I worry too much about too many things. He’s probably right. But here’s one worry I’d be remiss in not alerting people to: your water supply is not as safe – not nearly as safe – as you probably assume it is.

I’m not talking about the danger of lead pipes. I’m not even talking about the danger of microplastics in your water. I’ve warned about both of those before (and I’m still worried about them). No, I’m worried we’re not taking the danger of cyberattacks against our water systems seriously enough.

A week ago the EPA issued an enforcement alert about cybersecurity vulnerabilities and threats to community drinking water systems. This was a day after EPA head Michael Regan and National Security Advisor Jake Sullivan sent a letter to all U.S. governors warning them of “disabling cyberattacks” on water and wastewater systems, and urging them to cooperate in safeguarding those infrastructures.

“Drinking water and wastewater systems are an attractive target for cyberattacks because they are a lifeline critical infrastructure sector but often lack the resources and technical capacity to adopt rigorous cybersecurity practices,” the letter warned. It specifically cited known state-sponsored attacks from Iran and China.

The enforcement alert elaborated:

Cyberattacks against CWSs are increasing in frequency and severity across the country. Based on actual incidents we know that a cyberattack on a vulnerable water system may allow an adversary to manipulate operational technology, which could cause significant adverse consequences for both the utility and drinking water consumers. Possible impacts include disrupting the treatment, distribution, and storage of water for the community, damaging pumps and valves, and altering the levels of chemicals to hazardous amounts.

Next Gov/FCW paints a grim picture of how vulnerable our water systems are:

Multiple nation-state adversaries have been able to breach water infrastructure around the country. China has been deploying its extensive and pervasive Volt Typhoon hacking collective, burrowing into vast critical infrastructure segments and positioning along compromised internet routing equipment to stage further attacks, national security officials have previously said.

In November, IRGC-backed cyber operatives broke into industrial water treatment controls and targeted programmable logic controllers made by Israeli firm Unitronics. Most recently, Russia-linked hackers were confirmed to have breached a slew of rural U.S. water systems, at times posing physical safety threats.

Aftermath of a cyberattack on The Municipal Water Authority of Aliquippa. Credit" MWAA

We shouldn’t be surprised by these attacks. We’ve come to learn that China, Iran, North Korea, and Russia have highly sophisticated cyber teams, but, when it comes to water systems, it turns out the attacks don’t have to be all that sophisticated. The EPA noted that over 70% of water systems it inspected did not fully comply with security standards, including such basic protections such as not allowing default passwords.

NextGov/FCW pointed out that last October the EPA was forced to rescind requirements that water agencies at least evaluate their cyber defenses, due to legal challenges from several (red) states and the American Water Works Association. Take that in. I’ll bet China, Iran, and others are evaluating them.

“In an ideal world ... we would like everybody to have a baseline level of cybersecurity and be able to confirm that they have that,” Alan Roberson, executive director of the Association of State Drinking Water Administrators, told AP. “But that’s a long ways away.”

Tom Kellermann, SVP of Cyber Strategy at Contrast Security told Security Magazine: “The safety of the U.S. water supply is in jeopardy. Rogue nation states are frequently targeting these critical infrastructures, and soon we will experience a life-threatening event.” That doesn’t sound like a long ways away.

Similarly, Professor Blair Feltmate, an expert in water systems at the University of Waterloo in Canada, told Newsweek: “The U.S. Southwest is on the edge of being out of water, due to a combination of climate-change driven extreme heat, growing drought and excess demand. Nonetheless, survival in the Southwest depends on this increasingly precarious water supply—as such, cyber bad guys will likely target this region using a 'kick 'em while they are down' logic.”

On the other hand, David Reckhow, Emeritus professor at UMass Amherst, also told Newsweek: “All community water systems are somewhat vulnerable to intentional contamination, but it's unlikely that cyberattack would result in a serious compromise in water quality or public health. On the other hand, a cyberattack could result in financial difficulties.”

In the interim, the EPA plans to increase the number of planned inspections, but EPA spokesperson Jeffrey Landis admitted to CNN the agency is “not receiving additional resources to support this effort.” It has 88 credentialled inspectors; there are something like 50,000 community water systems. Those are not encouraging ratios. I’ll bet Iran’s IRGC and China’s Volt Typhoon have more than 88 hackers…each.

Part of the problem is that many water systems just haven’t seen cybersecurity as key to what they do. Amy Hardberger, a water expert at Texas Tech University, told CBS News: “Certainly, cybersecurity is part of that, but that's never been their primary expertise. So, now you're asking a water utility to develop this whole new sort of department.”

Yes, we are.

I hope a lot of water systems take this. Credit: EPA

Frank Ury, president of the board of the Santa Margarita Water District in southern California, told The Wall Street Journal that he’s worried hackers might have penetrated systems and are lying dormant until a coordinated attack. Jake Margolis, Chief Information Security Officer of The Metropolitan Water District of Southern California, agrees, and warns: “Even if you’re doing everything right, it’s still not enough.” And we’re not even doing everything right.

It’s not as though water systems are all that robust generally. Drinking water infrastructure got a C- in the last ASCE Infrastructure Report Card, with the acknowledgement: “Unfortunately, the system is aging and underfunded.” It could have added: “and woefully unprepared for cyberattacks.”

So, we could have our water shut off, or made undrinkable through changes to how the water is processed. We’ve seen how corporations respond to ransom demands when, say, data is held hostage; what would we agree to in order to get safe water back? We worry about missiles carrying bombs or chemical weapons, so why aren’t we more worried about attacks to the safety of our water? 

And, in case you were wondering, water infrastructure is not the only infrastructure vulnerable to cyberattacks; the electric grid and even dams have been targeted. But safe water is about as basic a need as there is.

Safe water was one of the greatest public health triumphs of the 20^th century. Let’s hope we can keep it safe in the 21^st century.  

Getting the Future of Healthcare Wrong

Sure, there’s lots of A.I. hype to talk about (e.g., the AI regulation proposed by Chuck Schumer, or the latest updates from Microsoft, Google, and OpenAI) but a recent column by Wall Street Journal tech writer Christopher Mims – What I Got Wrong in a Decade of Predicting the Future of Tech --  reminded me how easily we get overexcited by such things.   

The future? Maybe. Credit: Gerd Altmann from Pixabay

I did my own mea culpa about my predictions for healthcare a couple of years ago, but since Mr. Mims is both smarter and a better writer than I am, I’ll use his structure and some of his words to try to apply them to healthcare.  

Mr. Mims offers five key learnings:

1. Disruption is overrated
2. Human factors are everything
3. We’re all susceptible to this one kind of tech B.S.
4. Tech bubbles are useful even when they’re wasteful
5. We’ve got more power than we think

Let’s take each of these in turn and see how they relate not just to tech but also to healthcare.

Disruption is overrated

“It’s not that disruption never happens,” Mr. Mims clarifies. “It just doesn’t happen nearly as often as we’ve been led to believe.”  Well, no kidding. I’ve been in healthcare for longer than I care to admit, and I’ve lost count of all the “disruptions” we were promised.

The fact of the matter is that healthcare is a huge part of the economy. Trillions of dollars are at stake, not to mention millions of jobs and hundreds of billions of profits. Healthcare is too big to fail, and possibly too big to disrupt in any meaningful way.

If some super genius came along and offered us a simple solution that would radically improve our health but slash more than half of that spending and most of those jobs, I honestly am not sure we’d take the offer. Healthcare likes its disruption in manageable gulps, and disruptors often have their eye more on their share of those trillions than in reducing them.

For better or worse, change in healthcare usually comes in small increments.

Yeah, most disruption is just talk. Credit: Eden Costantino on Unsplash

Human factors are everything

“But what’s most often holding back mass adoption of a technology is our humanity,” Mr. Mims points out. “The challenge of getting people to change their ways is the reason that adoption of new tech is always much slower than it would be if we were all coldly rational utilitarians bent solely on maximizing our productivity or pleasure.” 

Boy, this hits the healthcare head on the nail. If we all simply ate better, exercised more, slept better, and spent less time on our screens, our health and our healthcare system would be very different. It’s not rocket science, but it is proven science.

But we don’t. We like our short-cuts, we don’t like personal inconvenience, and why skip the Krispy Kreme when we can just take Wegovy? Figure out how to motivate people to take more charge of their health: that’d be disruption.

We’re all susceptible to this one kind of tech B.S.

Mr. Mims believes: “Tech is, to put it bluntly, full of people lying to themselves,” although he is careful to add: “It’s usually not malicious.” That’s true in healthcare as well. I’ve known many healthcare innovators, and almost without exception they are true believers in what they are proposing. The good ones get others to buy into their vision. The great ones actually make some changes, albeit rarely quite as profoundly as hoped.

But just because someone believes something strongly and articulates very well doesn’t mean it’s true. I’d like to see significant changes as much as anyone, and more than most, and I know I’m too often guilty of looking for what Mr. Mims calls “the winning lottery ticket” when it comes to healthcare innovation, even though I know the lottery is a sucker’s bet.

To paraphrase Ronald Reagan (!), hope but verify.

Tech bubbles are useful even when they’re wasteful

 Healthcare has its bubbles as well, many but not all of them tech related. How many health start-ups over the last twenty years can you name that did not survive, much less make a mark on the healthcare system? How many billions of investments do they represent?

But, as Mr. Mims recounts Bill Gates once saying, “most startups were “silly” and would go bankrupt, but that the handful of ideas—he specifically said ideas, and not companies—that persist would later prove to be “really important.”’  

The trick, in healthcare as in tech, is separating the proverbial wheat from the chaff, both in terms of what ideas deserve to persist and in which people/organizations can actually make them work. There are good new ideas out there, some of which could be really important.

Finding the right idea matters. Credit: Bing Image Creator

We’ve got more power than we think

Many of us feel helpless when encountering the healthcare system. It’s too big, too complicated, too impersonal, and too full of specialized knowledge for us to have the kind of agency we might like.

Mr. Mims advice, when it comes to tech is: “Collectively, we have agency over how new tech is developed, released, and used, and we’d be foolish not to use it.” The same is true with healthcare. We can be the patient patients our healthcare system has come to expect, or we can be the assertive ones that it will have to deal with.

I think about people like Dave deBronkart or the late Casey Quinlan when it comes to demanding our own data. I think about Andrea Downing and The Light Collective when it comes to privacy rights. I think about all the biohackers who are not waiting for the healthcare system to catch up on how to apply the latest tech to their health. And I think about all those patient advocates – too numerous to name – who are insisting on respect from the healthcare system and a meaningful role in managing their health.

Yes, we’ve got way more power than we think. Use it.

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Mr. Mims is humble in admitting that he fell for some people, ideas, gadgets, and services that perhaps he shouldn’t. The key thing he does, though, to use his words, is “paying attention to what’s just over the horizon.” We should all be trying to do that, and doing our best to prepare for it.

My horizon is what a 22^nd century healthcare system could, will and should look like. I’m not willing to settle for what our early 21^st century one does. I expect I’ll continue to get a lot wrong but I’m still going to try.

 

It's the Administrators, Stupid

Universities are having a hard time lately. They’re beset with protests the like of which we’ve not seen since the Vietnam War days, with animated crowds, sit-ins, violent clashes with police or counter protesters, even storming of administration buildings. Classes and commencements have been cancelled. Presidents of some leading universities seemed unable to clearly denounce antisemitism or calls for genocide when asked to do so in Congressional hearings. Protesters walked out on Jerry Seinfeld’s commencement speech; for heaven’s sake – who walks out on Jerry Seinfeld?

Administrators in Meeting World. Credit: Bing Image Creator

Derek Thompson wrote a great piece for The Atlantic that tries to pinpoint the source problem: No One Knows What Universities Are For. The sub-title sums up his thesis: “Bureaucratic bloat has siphoned power away from instructors and researchers.”  As I was nodding along with most of his points, I found myself also thinking: he might as well be talking about healthcare.

Mr. Thompson starts by citing a satirical piece in The Washington Post, in which Gary Smith, an economics professor at Pomona College, argues that, based on historical trends in the growth of administration staff, the college would be best served by gradually eliminating faculty and even students. The college’s endowment could then be used just to pay the administrators.

“And just like that,” Professor Smith says, “the college would be rid of two nuisances at once. Administrators could do what administrators do — hold meetings, codify rules, debate policy, give and attend workshops, and organize social events — without having to deal with whiny students and grumpy professors.”

It’s humorous, and yet it’s not.

The growth in universities’ administrative staff is widespread. Mr. Thompson acknowledges: “As the modern college has become more complex and multifarious, there are simply more jobs to do.” But that’s not always helping universities’ missions. Political scientist Benjamin Ginsberg, who published The Fall of the Faculty: The Rise of the All-Administrative University and Why It Matters in 2014, told Mr. Thompson: “I often ask myself, What do these people actually do? I think they spend much of their day living in an alternate universe called Meeting World.”

Similarly, Professor Smith told Mr., Thompson it’s all about empire building; as Mr. Thompson describes it: “Administrators are emotionally and financially rewarded if they can hire more people beneath them, and those administrators, in time, will want to increase their own status by hiring more people underneath them. Before long, a human pyramid of bureaucrats has formed to take on jobs of dubious utility.”

All of these administrators add to the well-known problem of runaway college tuition inflation, but a more pernicious problem Mr. Thompson points to is that “it siphons power away from instructors and researchers at institutions that are—theoretically—dedicated to instruction and research.”

The result, Mr. Thompson concludes is “goal ambiguity.” Gabriel Rossman, a sociologist at UCLA, told him: “The modern university now has so many different jobs to do that it can be hard to tell what its priorities are.”  Mr. Thompson worries: “Any institution that finds itself promoting a thousand priorities at once may find it difficult to promote any one of them effectively. In a crisis, goal ambiguity may look like fecklessness or hypocrisy.”

So it is with healthcare.

Anyone who follows healthcare has seen some version of the chart that shows the growth in the number of administrators versus the number of physicians over the last 50 years; the former has skyrocketed, the latter has plodded along. One can – and I have in other forums – quibble over who is being counted as “administrators” in these charts, but the undeniable fact is that there are a huge number of people working in healthcare whose job isn’t, you know, to help patients.

It’s well documented that the U.S. healthcare system is by far the world’s most expensive healthcare system, and that we have, again by far, the highest percent spent on administrative expenses. Just as all the college administrators helps keep driving up college tuition, so do all those healthcare administrators keep healthcare spending high.

But, as Mr. Thompson worries about with universities, the bigger problem in healthcare is goal ambiguity. All those people are all doing something that someone finds useful but not necessarily doing things that directly related to what we tend to think is supposed to be healthcare’s mission, i.e., helping people with their health.  

Think about the hospitals suing patients. Think health insurers denying claims or making doctors/patients jump through predetermination hoops.  Think about the “non-profits” who not only have high margins but also get far greater tax breaks than they spend on charity care. Think about healthcare “junk fees” (e.g., facility fees). Think about all the people in healthcare making over a million dollars annually. Think about pharmaceutical companies who keep U.S. drug prices artificially high, just because they can.

As TV’s Don Ohlmeyer once said in a different context: “The answer to all of your questions is: Money.”

Healthcare is full of lofty mission statements and inspiring visions, but it is also too full of people whose jobs don’t directly connect to those and, in fact, may conflict with them. That leads to goal ambiguity.

Mr. Thompson concluded his article:

Complex organizations need to do a lot of different jobs to appease their various stakeholders, and they need to hire people to do those jobs. But there is a value to institutional focus…The ultimate problem isn’t just that too many administrators can make college expensive. It’s that too many administrative functions can make college institutionally incoherent.

Accordingly, I’d argue that the problem in healthcare isn’t that it has too many administrators per se, but that the cumulative total of all those administrators has resulted in healthcare becoming institutionally incoherent.

Famed Chicago columnist Mike Royko once offered a solution to Chicago’s budget problems. “It’s simple,” he said. “You ask city employees what they do. If they say something like “I catch criminals” or “I fight fires,” them you keep. If they say something like “I coordinate…” or “I’m the liaison…”, them you fire.”

Healthcare should have that kind of institutional focus, and that focus should be around patients and their health, not around money.

Twenty years ago Gerry Anderson, Uwe Reinhardt, and colleagues posited “It’s the Prices, Stupid” when it came to what distinguished the U.S. healthcare system, but now I’m thinking perhaps it’s the administrators.