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2 December 2012

Let It Be at the Prince of Wales Theatre – Beatles stream of consiciousness

Filed under: fun, healthcare, music, theatre — David Wood @ 11:03 am

“For our last number I’d like to ask your help. Would the people in the cheaper seats clap your hands? And the rest of you, if you’ll just rattle your jewelry”

These were the words used by John Lennon, on stage for the Royal Variety Performance at the Prince of Wales theatre in central London on 4th November 1963, to introduce the last number of the set played by the Beatles. The packed audience included the British royal family. Black and white archive film of the set exists:

That moment was part of a period of a few months when the phenomenon of “Beatlemania” burst into the public consciousness. As told by Beatles historian Bruce Spizer,

By September 1963, The Beatles were gaining coverage in the British press and were receiving tremendous radio and television exposure. But their big break through was a widely-watched and well-publicized television appearance on “Val Parnell’s Sunday Night at the London Palladium”, which was televised throughout the U.K. during prime time Sunday evening and was the British equivalent of “The Ed Sullivan Show”. The Beatles headlined the Oct. 13, 1963, Palladium show, which was seen by more than 15 million people. The bedlam caused by the group both inside and outside the theater caught the attention of British news editors, who elevated The Beatles from a successful entertainment act to a national news phenomenon. The Daily Mirror described the hysteria as “Beatlemania!” The term stuck.

The Beatles’ triumphant Palladium appearance was quickly followed by the Oct. 31 airport reception witnessed by Sullivan and their playing before British high society at the Royal Command Performance, also known as the Royal Variety Show. Their presence on the Nov. 4, 1963, show drew more attention than the arrival of Royal Family. The Beatles, who were seventh on the bill of 19 acts, impressed the upscale crowd with “She Loves You”, “Till There Was You”, “From Me To You” and “Twist and Show”. Prior to ripping into a rousing rendition of their closing rocker, Lennon said, “For our last number I’d like to ask your help. Would the people in the cheaper seats clap your hands? And the rest of you, if you’ll just rattle your jewelry.” While [Beatles manager Brian] Epstein viewed John’s remarks as being a bit risque, he was relieved that the crowd seemed charmed by the Beatle’s cheeky humor. Before the show, John had joked to Brian that he was going to ask the Royals to rattle their “fookin’ jewelry.”

Nearly fifty years later, the show “Let It Be”, playing at the very same Prince of Wales theatre, re-created a great deal of the same music, musicianship, and mannerisms of the original act. Including the jewelry quip.

LetItBeI had the great pleasure of viewing the show last night – and it was, indeed, a great pleasure.

There’s no plot. It’s simply a group of four musicians who look and sound remarkably similar to the original Beatles, playing a series of sets of fabulous music, interspersed (allowing the band a chance to change clothing – and wigs) with archive news footage, mock advertisements conveying a wistful sense of the 1960s, and audio excerpts of retrospective interviews by the Beatles.

The show progresses through segments (each with their own clothing and hairstyles)

  • the 1963 Royal Variety Show era,
  • a set from the 1965 Shea Stadium concert – where the Beatles had played to an audience of more than 55,000
  • a Sergeant Pepper segment
  • a flower power segment featuring All You Need is Love, Magical Mystery Tour, and more
  • a quieter section, with the group members seated for evocative melodies such as Norwegian Wood and Blackbird
  • an Abbey Road segment, culminating in a powerful rendition of The End
  • a final encore – including (of course) Let It Be, as well as a fore-taste of forthcoming solitary careers: Give Peace A Chance.

I offer a few thoughts from my stream of consciousness during the performance:

  • On either side of the stage, large screens showed images to frame the main actions. The young women who were shouting and screaming with such hysteria must in many cases be grandmothers by now – I wonder if they know their images are still delighting London audiences, nearly fifty years after their rush of blood was captured on camera
  • The vibrant twanging of Get Back mentally transported me back in time to April 1969, when I remember being enthralled, as a very naive ten-year old, by that song playing on Top of The Pop: “Sweet Loretta Martin thought she was a woman, But she was another man…”
  • The vocals to Lucy in the Sky with Diamonds and A Day in the Life were, if anything, even more trippy than in the original
  • Actually the audience seemed bemused and unsure about A Day in the Life, with many of them showing blank faces as the cacophony grew – I guess this song is nothing like as well known nowadays. And the clincher: half the audience started applauding the end of this song too soon, before that final apocalyptic multi-piano E Major chord rang out, woops
  • Perhaps another sign of the differentially fading memories of the Beatles music – the audience were happy to rise to its feet to sway along to Twist and Shout in the opening section, but when a similar request was made to stand up during Sgt Pepper Reprise, everyone sat stuck in their seats
  • A nice touch of fidelity in the Abbey Road segment – the “Paul McCartney” character was barefoot on stage – as on the Abbey Road album cover photo
  • For sheer musicianship, the guitar crescendo at the end of While My Guitar Gently Weeps was outstanding; that has always been one of my favourite Beatles tracks – particularly in its remastered version on the Love album remix – but it seemed particularly dramatic on stage this evening.

With such a rich music portfolio to choose from, inevitably many favourites have to be excluded from the two-hour show. Personally I would have missed out one or two of the tracks chosen, in order to find room for glorious stomping classics such as Lady Madonna, Hello Goodbye, The Walrus, or Back In the USSR.  For example, I’ve probably heard Hey Jude enough times already in my life, but its iconic status presumably meant it needed to be included.

Is this the show with the best set of music ever? Seeing that the competition includes Mamma Mia (with its feast of Abba hits), Westside Story (with its feast of Bernstein), and Amadeus (with its feast of Mozart), the answer is perhaps not – but it was still a tremendous occasion, providing a welcome break from thoughts about futurism, existential risk, free markets, and mobile phone technology!

Footnote: But I could not forget about mobile phone technology altogether that evening. On the way home, my companion found that her London Travel Card was being systematically rejected by tube turnstiles – again. That’s despite having bought the ticket only a few hours earlier. It’s by no means the first occurrence for her. “Is it OK to carry my travel card here, right next to my mobile phone, in this small section of my handbag?” she asked. “That is exactly the problem”, I answered – and there seems to be plenty of knowledge of this problem online. And the Beatles music faded out of my mind, to be replaced by thoughts on the health implications of proximity of mobile phones to the human body.

15 April 2012

Hope for healing healthcare

Filed under: books, change, Economics, healthcare, market failure, medicine, passion — David Wood @ 12:45 am

Within the space of the first few pages of his book “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care“, T.R. Reid had me chuckling at some of his descriptions of healthcare systems around the world. Within these same few pages, he also triggered in me a wave of anger and disbelief. He’s a veteran foreign correspondent for the Washington Post, and his writing skills shine throughout his book. Marshaling personal anecdotes from his experiences during visits to healthcare facilities in ten different countries, with historical accounts of how these healthcare systems came to have their current form, his writing addressed both my head and my heart.

Given the title of the book, it’s no spoiler for me to reveal that the episode in the first few pages that triggered my feeling of anger and disbelief was located in the USA. NY Times journalist Nicholas D. Kristof also read T.R. Reid’s book and had the same reaction as me. He retells the story in his article “The Body Count at Home“:

Nikki White was a slim and athletic college graduate who had health insurance, had worked in health care and knew the system. But she had systemic lupus erythematosus, a chronic inflammatory disease that was diagnosed when she was 21 and gradually left her too sick to work. And once she lost her job, she lost her health insurance.

In any other rich country, Nikki probably would have been fine, notes T. R. Reid in his important and powerful new book, “The Healing of America.” Some 80 percent of lupus patients in the United States live a normal life span. Under a doctor’s care, lupus should be manageable…

As Mr. Reid recounts, Nikki tried everything to get medical care, but no insurance company would accept someone with her pre-existing condition. She spent months painfully writing letters to anyone she thought might be able to help. She fought tenaciously for her life.

Finally, Nikki collapsed at her home in Tennessee and was rushed to a hospital emergency room, which was then required to treat her without payment until her condition stabilized. Since money was no longer an issue, the hospital performed 25 emergency surgeries on Nikki, and she spent six months in critical care.

“When Nikki showed up at the emergency room, she received the best of care, and the hospital spent hundreds of thousands of dollars on her,” her step-father, Tony Deal, told me. “But that’s not when she needed the care.”

By then it was too late. In 2006, Nikki White died at age 32. “Nikki didn’t die from lupus,” her doctor, Amylyn Crawford, told Mr. Reid. “Nikki died from complications of the failing American health care system.”...

Alas, the case of Nikki White is very far from being an exception. Kristof notes the estimates that “18,000 Die a Year for Lack of Insurance” each year in the US. (And numerous online responses to his blog post give other sad personal experiences.)

But here’s what I found really stomach-churning in the opening pages of T.R. Reid’s book:

Many Americans intensely dislike the idea that we might learn useful policy ideas from other countries, particularly in medicine. The leaders of the healthcare industry and the medical profession, not to mention the political establishment, have a single, all-purpose response they fall back on whenever someone suggests that the United States might usefully study foreign healthcare systems: “But it’s socialized medicine!”

This is supposed to end the argument. The contention is that the United States, with its commitment to free markets and low taxes, could never rely on big-government socialism the way other countries do. Americans have learned in school that the private sector can handle things better and more efficiently than government ever could.

In US policy debates, the term “socialized medicine” has been a powerful political weapon…  The term was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman’s proposal for a national healthcare system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to healthcare must be a communist. And the phrase has retained its political power for six decades…

I was reminded of the remarkable claims at the beginning of this year by would-be President Rick Santorum that the “NHS devastated Britain” and caused “the collapse of the British Empire”.

T.R. Reid had been bureau chief for the Washington Post in both London and Tokyo, and had lived in each of these cities for several years with his family. That gave him considerable first-hand experience of the healthcare systems in these two countries. The book arose from a wider set of visits, including France, Germany, Canada, India, Nepal, Switzerland, and Taiwan. He had two reasons for all these visits:

  1. To inquire about possible treatments for a shoulder injury he had sustained many years previously, but which had recently flared up again, becoming increasingly painful and hard to move. As he explained, “I could no longer swing a golf club. I could barely reach up to replace a lightbulb overhead or get the wine-glasses from the top shelf. Yearning for surcease from sorrow, I took that bum shoulder to doctors and clinics… in countries around the world”
  2. To seek, more generally, for “a solution to a much bigger medical problem… a prescription to fix the seriously ailing healthcare system” of the US.

He retells his diverse experiences with good humour and great insight. Along the way, he lists and punctures “Five Myths About Health Care in the Rest of the World” – myths that are widely believed in some parts of the US, but which have limited basis in actual practice:

  1. It’s all socialized medicine out there
  2. Overseas, care is rationed through limited choices or long lines
  3. Foreign health-care systems are inefficient, bloated bureaucracies
  4. Cost controls stifle innovation
  5. Health insurance has to be cruel

For example, on whether cost controls stifle innovation, he notes the following:

The United States is home to groundbreaking medical research, but so are other countries with much lower cost structures. Any American who’s had a hip or knee replacement is standing on French innovation. Deep-brain stimulation to treat depression is a Canadian breakthrough. Many of the wonder drugs promoted endlessly on American television, including Viagra, come from British, Swiss or Japanese labs.

Overseas, strict cost controls actually drive innovation. In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)

And the facts and figures throughout the book are relentless and comprehensive:

  • Average life expectancy at birth in the United States is 77.85 years. “That means the world’s richest country ranks forty-seventh, just ahead of Cyprus and a little behind Bosnia and Herzegovina, in terms of longevity. The United States is among the worst of the industrialized nations on this score; for that matter, the average American can expect a shorter life than people in relatively poor countries like Jordan”
  • “For those Americans who are uninsured or under-insured, any bout with illness can be terrifying on two levels. In addition to the risk of disability or death due to the disease, there’s the risk of financial ruin due to the medical and pharmaceutical bills. This is a uniquely American problem. When I was traveling the world on my quest, I asked the health ministry of each country how many citizens had declared bankruptcy in the past year because of medical bills. Generally, the officials responded to this question with a look of astonishment, as if I had asked how many flying saucers from Mars landed in the ministry’s parking lot last week. How many people go bankrupt because of medical bills? In Britain, zero. In France, zero. In Japan, Germany, the Netherlands, Canada, Switzerland: zero. In the United States, according to a joint study by Harvard Law School and Harvard Medical School, the annual figure is around 700,000”
  • “The one area where the United States unquestionably leads the world is in spending. Even countries with considerably older populations, with more need for medical attention, spend much less than we do. Japan has the oldest population in the world, and the Japanese go to the doctor more than anybody – about fourteen office visits per year, compared with five for the average American. And yet Japan spends about $3,000 per person on health care each year; we burn through $7,000 per person”
  • “When a Harvard Medical School professor working at the World Health Organisation developed a complicated formula to rate the quality and fairness of national healthcare systems around the world, the richest nation on earth ranked thirty-seventh… just behind Dominica and Costa Rica, and just ahead of Slovenia and Cuba…”

(For more about the WHO comparative rankings of healthcare systems, see e.g. Wikipedia’s coverage. T.R. Reid addresses various criticisms of the methodology in an Appendix to his book.)

Rising above the facts and figures, and the various anecdotes, the book provides a handy framework for making sense of the different systems deployed around the world:

“Fortunately, for all the local variations, health care systems tend to follow general patterns. In some models, government is both the provider of health care and the payer. In others, doctors and hospitals are in the private sector but government pays the bills. In still other countries, both the providers and the payers are private.”

There are four basic models:

  1. The Bismarck Model: “Both health care providers and payers are private entities. The model uses private health insurance plans, usually financed jointly by employers and employees through payroll deduction. Unlike the U.S. health insurance industry, though, Bismarck-type plans are basically charities: They cover everybody, and they don’t make a profit”
  2. The Beveridge Model: “Health care is provided and financed by the government, through tax payments. There are no medical bills; rather, medical treatment is a public service, like the fire department or the public library. In Beveridge systems, many (sometimes all) hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge”
  3. The National Health Insurance Model: “The providers of health care are private, but the payer is a government-run insurance program that every citizens pays into. The national, or provincial, insurance plan collects monthly premiums and pays medical bills. Since there’s no need for marketing, no expensive underwriting offices to deny claims, and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style private insurance. As a single payer covering everybody, the national insurance plan tends to have considerable market power to negotiate for lower prices. NHI countries also control costs by limiting the medical services they will pay for or by making patients wait to be treated.”
  4. The Out-of-pocket model: “Most medical care is paid for by the patient, out of pocket, with no insurance or government plan to help”.

Which all these systems apply in the US? The answer, surprisingly, is: All of the above – but not done in an efficient way.

Chapter by chapter, the book highlights ways in which the various medical systems keep costs lower (e.g. through having simpler administration) and deliver generally higher quality than applies in the US.

But two examples are even more important than any mentioned so far. These are the examples of Switzerland and Taiwan. Both of these are countries where significant reforms in the healthcare system have recently taken place – putting the lie to any viewpoint that complicated healthcare systems are incapable of major improvement:

Neither of these countries looks much like the United States of America… Still, both countries have important parallels to the United States. Both are vigorous democracies marked by fierce competition between political parties that look a lot like our Republicans and Democrats. Both have finance and insurance industries that are rich and politically influential. Both are ferociously capitalist places, and both have jumped aboard the digital revolution to build advanced, high-tech economies. Most important, both Taiwan and Switzerland had fragmented and expensive health care, similar to the American system – until they launched their reform campaigns.

In both countries, payment for medical care was dominated by health insurance plans tied to employment; in both significant numbers of people were left with no coverage at all. Even with large numbers of people uninsured, both countries were pouring considerable amounts of money into health care. In both Taiwan and Switzerland, as in the United States…, a growing chorus of voices began demanding universal coverage, arguing that every sick person should have access to a doctor…

In both cases, the results of the reforms have been very positive. To take the case of Taiwan:

Almost overnight, some 11 million Taiwanese who had no medical insurance suddenly had access to doctors and hospitals, with the Bureau of National Health Insurance paying most of the bill. This created a flood of new demand for medical services. The market responded with a flood of new supply: Clinics, hospitals, dentists, optometrists, labs, hostels, and acupuncture centers sprang up everywhere…

The most striking result of Taiwan’s new system is a healthier population with a longer healthy life expectancy and much higher recovery rates from major diseases. This is particularly evident in rural areas, where it was difficult or impossible to see a doctor before the new system took place…

As a system started from scratch, with uniform rules and procedures for every doctor and patient and state-of-the-art paperless record-keeping, Taiwan’s new health insurance system is the most efficient in the world. The 1994 law seemed hopelessly optimistic when it set a limit of 3.5% for administrative costs; in fact, the system has done much better than that, with paperwork, etc. accounting for only 2% of costs most years (and sometimes less). That’s about… one-tenth as high as the administrative burden for America’s private health insurers. As a result, even with explosive growth in the consumption of medical services, national health spending in Taiwan remains at about 6% of gross domestic product (as opposed to about 17% of GDP in the United States). This has kept costs low for patients…

As for the healthcare reforms in the US, under President Obama, T.R. Reid points out that they miss various elements of the reforms undertaken in both Taiwan and Switzerland:

  • Even with the reform in place, there will still be around 23 million Americans without healthcare insurance in 2019
  • American health insurance companies will still be able to get away with various practices (for denying payments to patients) that are banned in every other rich democracy
  • Much of the argumentation in favour of the reform has emphasised economics (not a bad thing in itself), but the moral and ethical drivers which were at the forefront in the debates in Taiwan and Switzerland have had a much lower profile in the US.

The final passage in the main body of the book puts it like this:

The sad truth is that, even with this ambitious reform, the United States will still have the most complicated, the most expensive, and the most inequitable healthcare system of any developed nation. The new law won’t get to the destination all other industrialized democracies have reached: universal healthcare coverage at reasonable cost. To achieve that goal, the United States will still have to take some lessons from the other national healthcare systems described in this book.

I’ll touch on four points in my own conclusion:

1. The moral argument for healthcare reform

The time I’ve spent recently reading Jonathan Haidt’s “The Righteous Mind” and watching him speak at a couple of events in London, has made me more sensitive to the fact that different people have different moral “tastes”, and can assign different priorities to six major dimensions of moral sensibility:

  • care vs. harm
  • fairness vs. cheating
  • liberty vs. oppression
  • loyalty vs. betrayal
  • authority vs.subversion
  • sanctity vs. degradation.

Failure to appreciate this fact leads of lots of bewilderment, as summarised in William Saletan’s New York Times review “Why won’t they listen?” of Haidt’s book. As T.R. Reid highlights, the current US healthcare system may well fail important moral tests on grounds of care vs. harm, and by being “unfair”. However, the arguments of people like Rick Santorum against the reform act build on different moral dimensions – e.g. liberty vs. oppression. These arguments find it particularly objectionable that, under these reforms, many people will be obliged (“oppressed”) into purchasing healthcare insurance. That’s seen as a fundamental denial of liberty.

Another insight from Haidt is that, in these circumstances of conflicting moral intuitions, reasoning often fails. One of his key summary points is as follows:

Moral intuitions come first, strategic reasoning comes second, to justify the intuitions we have already reached.

That’s not to say further discussion is pointless. As William Saletan puts it:

Haidt believes in the power of reason, but the reasoning has to be interactive. It has to be other people’s reason engaging yours. We’re lousy at challenging our own beliefs, but we’re good at challenging each other’s. Haidt compares us to neurons in a giant brain, capable of “producing good reasoning as an emergent property of the social system.”

Our task, then, is to organize society so that reason and intuition interact in healthy ways. Haidt’s research suggests several broad guidelines. First, we need to help citizens develop sympathetic relationships so that they seek to understand one another instead of using reason to parry opposing views. Second, we need to create time for contemplation. Research shows that two minutes of reflection on a good argument can change a person’s mind. Third, we need to break up our ideological segregation. From 1976 to 2008, the proportion of Americans living in highly partisan counties increased from 27% to 48%. The Internet exacerbates this problem by helping each user find evidence that supports his views…

2. A surprisingly effective example of lower-cost healthcare

So, what happened to T.R. Reid’s shoulder? Out of the all the recommendations from different doctors around the world, which was the best?

Doctors in several countries – including the US – recommended expensive, invasive, reconstructive surgery – even though all these doctors noted that there was no guarantee the surgery would be successful.

But the advice T.R. Reid ultimately found most useful involved a very different kind of technology, with roots going far back into time. That treatment was in India, and was based on Ayurdveda – which, like yoga, is derived from ancient Hindu scripture. It included

  • Eating only bland food (lentils and rice, primarily) during the course of the treatment, on the theory that the body should be under minimal strain during treatment
  • Daily massages involving hot oils and powerful hand movements (“to smooth the bodily routes that the prana needs to follow”)
  • Six times each day, imbibing “a vile assortment of herbal medicines, most of which tasted like spoiled greens or aging mud”
  • Attending a temple within the hospital grounds, “to perform poojah, or reverence, tot he Hindu god of healing”
  • Undertaking various yogic exercises
  • Accepting advice to “relax, and to forget whatever stresses and worries”
  • Reading one of the key Hindu scriptures, the Bhagavad Gita.

After several weeks of this treatment, the results were unmistakable. The shoulder had a much greater range of movement than before, and the pains were much reduced:

To this day, I don’t know why it happened. Was it the massage, the medication, the meditation…? In any case, the timing was definitely propitious. Ayurveda worked for me. I didn’t have a miracle cure; my shoulder was not completely healed. But my pain decreased, my range of motion increased, and I was definitely better – and all without the trouble or cost of a total shoulder arthoplasty…

Note that the book also describes some alternative medical treatments that were not successful – including other herbal medicines in Nepal, and acupuncture in Taiwan. And as mentioned, the Ayurveda did not provide “complete” healing. What’s more, Ayurvedic clinics increasingly incorporate x-ray machines, stethoscopes, and other western tools. But this section of the book was an intriguing reminder to me that I’d love to dig more deeply into material such as William Broad’s “The science of yoga: the risks and the rewards“.

3. Every healthcare system is under increasing financial strain

Despite the many successes of healthcare systems covered in the book, T.R. Reid was clear that all these systems are under increasing financial stress. He quotes the (somewhat tongue-in-cheek) “Universal Laws of Healthcare Systems” as articulated by economist Tsung-Mei Cheng:

  1. No matter how good the health care in a particular country, people will complain about it.
  2. No matter how much money is spent on health care, the doctors and hospitals will argue it is not enough.
  3. The last reform always failed.

As the author states,

All national health systems, even those that do their job well, are fighting a desperate battle these days against rising costs.

We live in a technological age, and technology – in the form of new miracle drugs, new medical devices (e.g. man-made shoulders) and new procedures – plays a huge role in modern medicine. This is unquestionably a good thing… but it is also an expensive thing.

But good technology, wisely applied, can reduce healthcare costs, rather than simply make them more expensive. For example, as T.R. Reid points out, suitable early tests can do wonders in preventive medicine. One place I’ve covered this topic before is in “Smartphone technology, super-convergence, and the great inflection of medicine“.

4. The good news in American medicine

Lest it be thought that T.R. Reid, the author of “The healing of America”, is unduly negative about America, or unpatriotic, let me draw attention to a 53 minute PBS documentary he has recently released: “The good news in American medicine“.

Whereas “The healing of America” gathers inspiring examples of best practice from around the globe, “The good news in American medicine” gathers inspiring examples of best practice from around the US – and draws out some important economic and moral principles along the way. (Quote: “A whole lot of this is about doing the right thing“.) Just as I recommend the book, I also recommend the video.

25 March 2012

Smartphone technology, super-convergence, and the great inflection of medicine

Filed under: books, Connected Health, converged medicine, healthcare, Internet of Things, medicine — David Wood @ 10:07 pm

You are positioned to reboot the future of medicine…”

That’s the rallying cry that rings out from Eric Topol’s marvellous recent book “The Creative Destruction of Medicine”.  The word “Destruction” is meant in the sense elaborated by Austrian-Hungarian economist Joseph Schumpeter.  To quote from Investopedia:

Creative destruction occurs when something new kills something older. A great example of this is personal computers. The industry, led by Microsoft and Intel, destroyed many mainframe computer companies, but in doing so, entrepreneurs created one of the most important inventions of the century.

Topol believes that a similar transformation is underway in medicine.  His book describes at some length what he calls a “super-convergence” of different technological transformations:

  • Genomics, which increasingly indicates connections between individuals’ DNA sequences and their physiological responses to specific drugs and environmental conditions
  • Numerous small sensors – wearable (within clothing) or embeddable (within the body) – that can continuously gather key physiological data, such as blood glucose level, heart rhythm, and blood pressure, and transmit that data wirelessly
  • Improvements to imaging and scanning, that provide clearer information as to what is happening throughout the body (including the brain)
  • Enormous computing power that can manipulate vast amounts of data and spot patterns in it
  • Near ubiquitous smartphones, which can aggregate data from sensors, host all kinds of applications related to health and wellness, and provide early warnings on the need for closer attention
  • 3D manufacturing and synthetic biology, that can create compounds of growing use in medical investigation and bodily repair
  • The adoption of electronic medical records, that allow healthcare professionals to be much more aware of medical history of their patients, reducing the number of problems arising from unexpected interactions between different treatments
  • The emergence of next generation social networks binding together patients with shared interest in particular diseases, allowing crowd-sourcing of new insight about medical conditions
  • Enhanced communications facilities, that enable medical professionals to provide advice and even conduct operations from far-distant locations
  • Improved, free medical training facilities, such as the short videos provided by the Khan Academy.

Topol has an impressive track record as a leading medical practitioner, and gives every sign that he knows what he is talking about.  Importantly, he maintains a critical, skeptical perspective.  He gives plenty of examples of where technology has gone wrong in medicine, as well as when it has done well.  His observation of the application of accelerating technology to medicine is far from a utopia.  There are two sorts of problematic factors: technology factors (including the complexity of the underlying science), and non-technology factors.

First, the technology factors.  The ways that individuals react to different medical treatment vary considerably: a drug that saves one life can have terrible side effects in other patients.  What’s more, diseases that were formerly conceived as single entities now appear to be multiple in nature.  However, the move from “population medicine” to “individual medicine”, enabled by advances in genomics and by powerful data analysis, offers a great deal of hope.  For one example of note, see the Wall Street Journal article, “Major Shift in War on Cancer: Drug Studies Focus on Genes of Individual Patients“.  The core principle is that of ever improving digital analysis of data describing individual people – something that Topol calls “digital high definition of humans” leading to “hyperpersonalisation of healthcare… fulfilling the dream of true prevention of diseases”.

But the non-technology factors are just as significant.  Instead of the complexity of the underlying science, this refers to the structure of the medical industry.  Topol has harsh words here, describing the medical establishment as “ultra-conservative”, “ossified”, and “sclerotic” – existing in a “cocoon” which has tended to isolate it from the advances in information technology that have transformed so many other industries.  Topol calls for “an end of the medical priesthood… the end of an era of ‘doctor knows best'”.  Associations of medical professionals who seek to block patients from seeing their own medical data (e.g. a detailed analysis of their personal DNA) are akin, Topol says, to the medieval priests who fought against the introduction of printing and who tried to prevent church congregations from reading the bible in their own hands.

Given such criticisms, it’s perhaps surprising to read the wide range of positive endorsements at the start of the book, from eminent leaders of the medical industry.  This includes:

  • The global president of R&D for Sanofi
  • The professor of genetics from Harvard Business School
  • The chairman and CEO of Medtronic
  • The professor and vice-chair of surgery from NY Presbyterian/Columbia University
  • The chief medical officer from Philips Healthcare
  • The executive vice president and chief of medical affairs from United Health Group
  • The president of the Salk Institute for Biological Studies

and many others.  And for a growing list of reviews of the book, including from many people deeply embedded in the medical industry, see this compendium on the 33 Charts blog.  What’s happening here is that Topol is drawing attention to structural issues inside the medical profession, which many other people recognise too.  This includes risk aversion, long training cycles that place little emphasis on information technology, funding models that emphasise treatment rather than prevention, tests that are unnecessary and dangerous, and lengthy regulatory processes.

If the problem is structural, within the medical industry, the fix is within the hands of patients.  As per the quote I started with,

You are positioned to reboot the future of medicine…”

Here’s the longer version of that quote:

With the personal montage of your DNA, your cell phone, your social network – aggregated with your lifelong health information and physiological and anatomic data – you are positioned to reboot the future of medicine.

Topol advocates patients take advantage of the tremendous computational power that is put into their hands by smartphones, running healthcare applications, connected to wireless sensors, and plumbed into increasingly knowledgeable social networks that have a focus on medical matters – sites such as PatientsLikeMe, CureTogether, and many others.

There’s an important precedent.  This is the way business professionals are taking their own favourite smartphones and/or tablet computers into their workplaces, and are demanding that they can access enterprise systems with these devices.  This trend – “bring your own device” (“BYOD”) – is itself a subset of something known as “the consumerisation of enterprise technology”.  People buy particular smartphones and tablets on account of their compelling ease of use, stunning graphics, accessible multimedia, and rich suite of value-add applications covering all sorts of functionality.  They enjoy using these devices – and expect to be able to be use them for work purposes too, instead of what they perceive as clunky and sluggish devices provided via official business channels.  IT departments in businesses all around the globe are having to scramble to respond.  Once upon a time, they would have laid down the law, “the only devices allowed to be used for business are ones we approve and we provide”.  But since the people bringing in their own personal devices are often among the most senior officials in the company, this response is no longer acceptable.

Just as people are bringing their favourite smartphones from their home life into their business life, they should increasingly be willing to bring them into the context of their medical treatment – especially when these devices can be coupled to data sensors, wellness applications, and healthcare social networks.  Just as we use our mobile devices to check our email, or the sports news, we’ll be using these devices to check our latest physiological data and health status.  This behaviour, in turn, will be driven by increasing awareness of what’s available.  And Topol is on a mission to increase that awareness.  Hence his frequent speaking engagements, including his keynote session at the December 2011 mHealth Summit in Washington DC, when I first became aware of him.  (You can find a video of this presentation here.)  And hence his authorship of this book, to boost public understanding of the impending inflection point in medicine.  The more we all understand what’s available and what’s possible, the more we’ll all get involved in this seismic patient-led transformation.

Footnote: Topol’s book is generally easy to read, but contains quite a lot of medical detail in places.  Another book which covers similar ground, in a way that may be more accessible to people whose background is in mobile technology rather than medicine, is “The Decision Tree: How to make better choices and take control of your health”, by executive editor of Wired magazine, Thomas Goetz.  Both Topol and Goetz write well, but Goetz has a particular fluency, and tells lots of fascinating stories.  To give you a flavour of the style, you can read chapter one free online.  Both books emphasise the importance of allowing patients access to their own healthcare data, the emergence of smart online networks that generate new insight about medical issues, and the tremendous potential for smartphone technology to transform healthcare.  I say “Amen” to all that.

29 December 2011

From hospital care to home care – the promise of Connected Health

Filed under: challenge, Connected Health, converged medicine, healthcare, mHealth, usability — David Wood @ 12:01 pm
  • At least one in four hospital patients would be better off being treated by NHS staff at home

That claim is reported on today’s BBC news website.  The article addresses an issue that is important from several viewpoints: social, financial, and personal:

NHS Confederation: Hospital-based care ‘must change’

The NHS in England must end the “hospital-or-bust” attitude to medical care, says the body representing health service trusts.

At least one in four patients would be better off being treated by NHS staff at home, figures suggest.

2012 will be a key year for the NHS as it tries to make £20bn in efficiency savings by 2015, according to the head of the NHS Confederation, Mike Farrar.

Ministers say modernising the NHS will safeguard its future.

Mr Farrar said: “Hospitals play a vital role but we do rely on them for some services which could be provided elsewhere.

“We should be concentrating on reducing hospital stays where this is right for patients, shifting resources into community services, raising standards of general practice, and promoting early intervention and self-care.

“There is a value-for-money argument for doing this, but it is not just about money and the public need to be told that – this is about building an NHS for the future.”

Mr Farrar said the required changes included treating frail people in their homes, and minimising hospital stays wherever possible.

Politicians and NHS leaders must show the public how these changes could improve care, rather than focusing on fears over the closure of hospital services, he added.

“Many of our hospitals know that the patients that they are treating in their beds on any given day could be treated better – with better outcomes for them and their families – if they were treated outside of hospitals in community or primary care,” he told BBC Radio 4’s Today programme.

Mr Farrar told Today that people had become used to “the hospital being a place of default” and that primary and community healthcare services had sometimes been under-funded.

But he said even where clinicians knew that better care could be provided outside of hospitals, and politicians accepted this privately, the public debate had not helped individuals understand that…

Some of the replies posted online are sceptical:

As a medical doctor based in hospitals, I believe this will not work logistically. Patients are sent to hospitals as they don’t get the specialist care in the community as the skills/services are inadequate/not in place. Patient attitudes must change as many come to a+e against GP advice as they don’t have confidence in community care…

As long as the selfish British public can’t be bothered looking after their own relatives and see hospitals as convenient granny-dumping centres, there is absolutely no way this would work.

There can not be a perfect solution. Not every family can care for a sick person full time, often due to them working. Hospital care may not be a perfect, yet in some cases it does free relatives to be able to work.  Outsourcing care too has a major downside, my wife has done that for years. 15 mins twice a day, can hardly be called acceptable if you apply some form of dignity to the patient.

I saw too many patients I nursed(often elderly or with pre-existing health conditions) kept in hospital too long because no one to care for them at home/wider community. This wasn’t great for them but also blocked an acute bed for someone else. In recent years the pendulum’s swung too far the other way: too many patients discharged without adequate support…

In summary: care in the community would be better in many, many cases, but it’s demanding and challenging:

  • There are social challenges: relatives struggle to put their own lives and careers on hold, to act as caregivers.
  • There are financial challenges: funding for medicine is often preferentially directed to large, centralised hospitals.
  • There are skills challenges: observation of complicated chronic health conditions is more easily carried out in the proximity of specialists.

However, the movement “from hospital care to home care” continues to gather steam – for good reason.  This was a major theme of the mHealth Summit I attended earlier this month in Washington DC.  I was particularly struck by a vision articulated by Rick Cnossen, director of worldwide health information technology at Intel:

In the next 10 years 50% of health care could be provided through the “brickless clinic,” be it the home, community, workplace or even car

As reported in the summary article by Kate Ackerman, “mHealth: Closing the Gap Between Promise and Adoption“:

Cnossen said the technology — such as mobile tools, telehealth, personal health records and social networking — already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

Fellow speaker Hamadoun Toure, secretary general of the International Telecommunication Union took up the same theme:

Mobile phones will increase personal access to health information, mHealth and broadband technology will improve data collection and disease surveillance, patient monitoring will improve and become more prevalent, and remote consulting and diagnosis will be enhanced, thanks to low-cost devices.

“In the near future, more people will access the Internet through mobile devices than through fixed devices,” Toure said. “We are witnessing the fastest change in human history, and I believe (we have) a great opportunity for social development.”

Connected health technology enables better remote monitoring of personal medical data, earlier warnings of potential relapses, remote diagnostics, quicker access to technical information, better compliance with prescription regimes, and much, much more.

But Kate Ackerman raises the question,

So if the technology already exists and leaders from both the public and private sectors see the need, why has progress in mobile health been slow?

It’s an important question.  Intel’s Rick Cnossen gives his answer, as follows:

“The challenge is not a technology problem, it’s a business and a workflow problem.”

Cnossen said, “At the end of the day, mHealth is not about smartphones, gadgets or even apps. It’s about holistically driving transformation,” adding, “mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors…”

He said health care clinicians can be resistant to change, adding, “We need to introduce technology into the way to do their business, not the other way around.”

Cnossen also said that payment reform is essential for “mHealth to survive and thrive.” He said, “We should not be fighting for reimbursement codes for each health device and app. That is ultimately a losing proposition. Instead, we must fight for payment reform to pay for value over volume, regardless of whether the care was provided in a bricks and mortar facility or was it at the home or virtually through electronic means.”

Personally, I would put the emphasis differently:

The challenge is not just a technology problem, it’s also a business and a workflow problem

Moreover, as the technology keeps on improving, it can often diminish the arguments that are raised against its adoption.  Improvements in quality, reliability, miniaturisation, and performance all make a difference.  Improvements in usability may make the biggest difference of all, as people find the experience in using the new technology to be increasingly reassuring.

I’ll finish by noting an excerpt from the keynote at the same conference by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services:

This is an incredible time to be having this conversation. When we talk about mobile health, we are talking about taking the biggest technology breakthrough of our time and using it to take on one of the greatest … challenges of our time. And while we have a way to go, we can already imagine a remarkable future in which control over your health is always within hand’s reach…

This future is not here yet, but it is within sight. And I look forward to working with you to achieve it.

16 October 2011

Human regeneration – limbs and more

Filed under: healthcare, medicine, rejuveneering, risks, Singularity — David Wood @ 1:57 am

Out of the many interesting presentations on Day One of the 2011 Singularity Summit here in New York, the one that left me with the most to think about was “Regenerative Medicine: Possibilities and Potential” by Dr. Stephen Badylak.

Dr Badylak is deputy director of the McGowan Institute for Regenerative Medicine, and a Professor in the Department of Surgery at the University of Pittsburg. In his talk at the Singularity Summit, he described some remarkable ways in which the human body could heal itself – provided we provide it with suitable “scaffolding” that triggers the healing.

One of the examples Dr Badylak discussed is also covered in a recent article in Discover Magazine, How Pig Guts Became the Next Bright Hope for Regenerating Human Limbs.  The article deserves reading all the way through. Here are some short extracts from the beginning:

When he first arrived in the trauma unit of San Antonio’s Brooke Army Medical Center in December 2004, Corporal Isaias Hernandez’s leg looked to him like something from KFC. “You know, like when you take a bite out of the drumstick down to the bone?” Hernandez recalls. The 19-year-old Marine, deployed in Iraq, had been trying to outfit his convoy truck with a makeshift entertainment system for a long road trip when the bomb exploded. The 12-inch TV he was clutching to his chest shielded his vital organs; his buddy carrying the DVDs wasn’t so lucky.

The doctors kept telling Hernandez he would be better off with an amputation. He would have more mobility with a prosthetic, less pain. When he refused, they took a piece of muscle from his back and sewed it into the hole in his thigh. He did all he could to make it work. He grunted and sweated his way through the agony of physical therapy with the same red-faced determination that got him through boot camp. He even sneaked out to the stairwell, something they said his body couldn’t handle, and dragged himself up the steps until his leg seized up and he collapsed.

Generally people never recovered from wounds like his. Flying debris had ripped off nearly 70 percent of Hernandez’s right thigh muscle, and he had lost half his leg strength. Remove enough of any muscle and you might as well lose the whole limb, the chances of regeneration are so remote. The body kicks into survival mode, pastes the wound over with scar tissue, and leaves you to limp along for life….

Hernandez recalled that one of his own doctors—Steven Wolf, then chief clinical researcher for the United States Army Institute of Surgical Research in Texas—had once mentioned some kind of experimental treatment that could “fertilize” a wound and help it heal. At the time, Hernandez had dismissed the therapy as too extreme. The muscle transplant sounded safer, easier. Now he changed his mind. He wanted his leg back, even if it meant signing himself up as a guinea pig for the U.S. Army.

So Hernandez tracked down Wolf, and in February 2008 the two got started. First, Wolf put Hernandez through another grueling course of physical therapy to make sure he had indeed pushed any new muscle growth to the limit. Then he cut open Hernandez’s thigh and inserted a paper-thin slice of the same material used to make the pixie dust: part of a pig’s bladder known as the extracellular matrix, or ECM, a fibrous substance that occupies the spaces between cells. Once thought to be a simple cellular shock absorber, ECM is now understood to contain powerful proteins that can reawaken the body’s latent ability to regenerate tissue.

A few months after the surgery healed, Wolf assigned the young soldier another course of punishing physical therapy. Soon something remarkable began to happen. Muscle that most scientists would describe as gone forever began to grow back. Hernandez’s muscle strength increased by 30 percent from what it was before the surgery, and then by 40 percent. It hit 80 percent after six months. Today it is at 103 percent—as strong as his other leg. Hernandez can do things that were impossible before, like ease gently into a chair instead of dropping into it, or kneel down, ride a bike, and climb stairs without collapsing, all without pain

The challenge now is replicating Hernandez’s success in other patients. The U.S. Department of Defense, which received a congressional windfall of $80 million to research regenerative medicine in 2008, is funding a team of scientists based at the University of Pittsburgh’s McGowan Institute for Regenerative Medicine to oversee an 80-patient study of ECM at five institutions. The scientists will attempt to use the material to regenerate the muscle of patients who have lost at least 40 percent of a particular muscle group, an amount so devastating to limb function that it often leads doctors to perform an amputation.

If the trials are successful, they could fundamentally change the way we treat patients with catastrophic limb injuries. Indeed, the treatment might someday allow patients to regrow missing or mangled body parts. With an estimated 1.7 million people in the United States alone missing limbs, promoters of regenerative medicine eagerly await the day when therapies like ECM work well enough to put the prosthetics industry out of business.

The interesting science is the explanation of the role of the ECM – the extracellular matrix, which provides the scaffolding that allows the healing to take place. The healing turns out to involve the body directing stem cells to the scaffolding. These stem cells then differentiate into muscle cells, nerve cells, blood cells, and so on. There’s also some interesting science to explain why the body doesn’t reject the ECM that’s inserted into it.

Badylak speaks with confidence of the treatment one day allowing the regeneration of damaged human limbs, akin to what happens with salamanders.  He also anticipates the healing of brain tissue damaged by strokes.

Later that morning, another speaker at the Singularity Summit, Michael Shermer, referred to Dr Badylak’s presentation. Shermer is a well-known sceptic – indeed, he’s the publisher of Skeptic magazine.  Shermer often participates in public debates with believers in various religions and new-age causes.  Shermer mentioned that, at these debates, his scientific open mindedness is sometimes challenged.  “OK, if you are open-minded, as you claim, what evidence would make you believe in God?”  Shermer typically gives the answer that, if someone with an amputated limb were to have that limb regrow, that would be reason for him to become a believer:

Most religious claims are testable, such as prayer positively influencing healing. In this case, controlled experiments to date show no difference between prayed-for and not-prayed-for patients. And beyond such controlled research, why does God only seem to heal illnesses that often go away on their own? What would compel me to believe would be something unequivocal, such as if an amputee grew a new limb. Amphibians can do it. Surely an omnipotent deity could do it. Many Iraqi War vets eagerly await divine action.

However, Shermer joked with the Singularity Summit audience, it now appears that Dr Badylak might be God.  The audience laughed.

But there’s a serious point at stake here. The Singularity Summit is full of talks about humans being on the point of gaining powers that, in previous ages, would have been viewed as Divine. With great power comes great responsibility. As veteran ecologist and environmentalist Stewart Brand wrote at the very start of his recent book “Whole Earth Discipline“,

We are as gods and HAVE to get good at it.

In the final talk of the day, cosmologist Professor Max Tegmark addressed the same theme.  He gave an estimate of “between 1/10 and 1/10,000” for the probability of human extinction during any decade in the near-term future – extinction arising from (for example) biochemical warfare, runaway global warming, nanotech pollution, or a bad super-intelligence singularity. In contrast, he said, only a tiny fraction of the global GDP is devoted to management of existential risks.  That kind of “lack of paying attention” meant that humanity deserved, in Tegmark’s view, a “mid-term rating” of just D-.  Our focus, far too much of the time, is on the next election cycle, or the next quarterly financial results, or other short term questions.

One person who is seeking to encourage greater attention to be paid to existential risks is co-founder of Skype, Jaan Tallinn (who earlier in the year gave a very fine talk at a Humanity+ event I organised in London).  Jaan’s main presentation at the 2011 Singularity Summit will be on Day Two, but he briefly popped up on stage on Day One to announce a significant new fundraising commitment: he will personally match any donations made over the weekend to the Singularity Institute, up to a total of $100,000.

With the right resources, wisely deployed, we ought to see collective human intelligence achieve lots more regeneration – not just of broken limbs, but also of troubled societies and frustrated lives – whilst at the same time steering humanity away from the existential risks latent in these super-powerful technologies.  The discussion will continue tomorrow.

1 May 2010

Costs of complexity: in healthcare, and in the mobile industry

Filed under: books, business model, disruption, healthcare, innovation, modularity, simplicity — David Wood @ 11:56 am

While indeed there are economies of scale, there are countervailing costs of complexity – the more product families produced in a plant, the higher the overhead burden rates.

That sentence comes from page 92 of “The Innovator’s Prescription: A disruptive solution for health care“, co-authored by Clayton Christensen, Jerome Grossman, and Jason Hwang.  Like all the books authored (or co-authored) by Christensen, the book is full of implications for fields outside the particularly industry being discussed.

In the case of this book, the subject matter is critically important in its own right: how can we find ways to allow technological breakthroughs to reduce the spiralling costs of healthcare?

In the book, the authors brilliantly extend and apply Christensen’s well-known ideas on disruptive change to the field of healthcare.  But the book should be recommended reading for anyone interested in either strategy or operational effectiveness in any hi-tech industry.  (It’s also recommended reading for anyone interested in the future of medicine – which probably includes all of us, since most of us can anticipate spending increasing amounts of time in hospitals or doctor’s surgeries as we become older.)

I’m still less than half way through reading this book, but the section I’ve just read seems to speak loudly to issues in the mobile industry, as well as to the healthcare industry.

It describes a manufacturing plant which was struggling with overhead costs.  At this plant, 6.2 dollars were spent in overhead expenses for every dollar spend on direct labour:

These overhead costs included not just utilities and depreciation, but the costs of scheduling, expediting, quality control, repair and rework, scrap maintenance, materials handling, accounting, computer systems, and so on.  Overhead comprised all costs that were not directly spent in making products.

The quality of products made at that plant was also causing concern:

About 15 percent of all overhead costs were created by the need to repair and rework products that failed in the field, or had been discovered by inspectors as faulty before shipment.

However, it didn’t appear to the manager that any money was being wasted:

The plant hadn’t been painted inside or out in 20 years.  The landscaping was now overrun by weeds.  The receptionist in the bare-bones lobby had been replaced long ago with a paper directory and a phone.  The manager had no secretarial assistance, and her gray World War II vintage steel desk was dented by a kick from some frustrated predecessor.

Nevertheless, this particular plant had considerably higher overhead burden rates than the other plants from the same company.  What was the difference?

The difference was in the complexity.  This particular plant was set up to cope with large numbers of different product designs, whereas the other plants (which had been created later) had been able to optimise for particular design families.

The original plant essentially had the value proposition,

We’ll make any product that anyone designs

In contrast, the newer plants had the following kind of value proposition:

If you need a product that can be made through one of these two sequences of operations and activities, we’ll do it for you at the lowest possible cost and the highest possible quality.

Further analysis, across a number of different plants, reached the following results:

Each time the scale of a plant doubled, holding the degree of pathway complexity constant, the overhead rate could be expected to fall by 15 percent.  So, for example, a plant that made two families and generated $40 million in sales would be expected to have an overhead burden ratio of about 2.85, while the burden rate for a plant making two families with $80 million in sales would be 15% lower (2.85 x 0.85 = 2.42).  But every time the number of families produced in a plant of a given scale doubled, the overhead burden rate soared 27 percent.  So if a two-pathway, $40 million plant accepted products that required two additional pathways, but that did not increase its sales volume, its overhead burden rate would increase by 2.85 x 1.27, to 3.62…

This is just one aspect of a long and fascinating analysis.  Modern day general purpose hospitals support huge numbers of different patient care pathways, so high overhead rates are inevitable.  The solution is to allow the formation of separate specialist units, where practitioners can then focus on iteratively optimising particular lines of healthcare.  We can already see this in firms that specialise in laser eye surgery, in hernia treatment, and so on.  Without these new units separating and removing some of the complexity of the original unit, it becomes harder and harder for innovation to take place.  The innovation becomes stifled under conflicting business models.  (I’m simplifying the argument here: please take a look at the book for the full picture.)

In short: reducing overhead costs isn’t just a matter of “eliminating obvious inefficiencies, spending less time on paperwork, etc”.  It often requires initially painful structural changes, in which overly complex multi-function units are simplified by the removal and separation of business lines and product pathways.  Only with the new, simplified set up – often involving new companies, and sometimes involving “creative destruction” – can disruptive innovations flourish.

Rising organisational complexity impacts the mobile industry too.  I’ve written about this before.  For example, in May last year I wrote an article “Platform strategy failure modes“:

The first failure mode is when a device manufacturer fails to have a strategy towards mobile software platforms.  In this case, the adage holds true that a failure to strategise is a strategy to fail.  A device manufacturer that simply “follows the wind” – picking platform P1 for device D1 because customer C1 expressed a preference for P1, picking platform P2 for device D2 because customer C2 expressed a preference for P2, etc – is going to find that the effort of interacting successfully with all these different platforms far exceeds their expectations.  Mobile software platforms require substantial investment from manufacturers, before the manufacturer can reap commercial rewards from these platforms.  (Getting a device ready to demo is one thing.  That can be relatively easy.  Getting a device approved to ship onto real networks – a device that is sufficiently differentiated to stand out from a crowd of lookalike devices – can take a lot longer.)

The second failure mode is similar to the first one.  It’s when a device manufacturer spreads itself  too thinly across multiple platforms.  In the previous case, the manufacturer ended up working with multiple platforms, without consciously planning that outcome.  In this case, the manufacturer knows what they are doing.  They reason to themselves as follows:

  • We are a highly competent company;
  • We can manage to work with (say) three significant mobile software platforms;
  • Other companies couldn’t cope with this diversification, but we are different.

But the outcome is the same as the previous case, even though different thinking gets the manufacturer into that predicament.  The root failure is, again, a failure to appreciate the scale and complexity of mobile software platforms.  These platforms can deliver tremendous value, but require significant ongoing skill and investment to yield that kind of result.

The third failure mode is when a manufacturer seeks re-use across several different mobile software platforms.  The idea is that components (whether at the application or system level) are developed in a platform-agnostic way, so they can fit into each platform equally well.

To be clear, this is a fine goal.  Done right, there are big dividends.  But my observation is that this strategy is hard to get right.  The strategy typically involves some kind of additional “platform independent layer”, that isolates the software in the component from the particular programming interfaces of the underlying platform.  However, this additional layer often introduces its own complications…

Seeking clever economies of scale is commendable.  But there often comes time when growing scale is bedevilled by growing complexity.  It’s as mentioned at the beginning of this article:

While indeed there are economies of scale, there are countervailing costs of complexity – the more product families produced in a plant, the higher the overhead burden rates.

Even more than a drive to scale, companies in the mobile space need a drive towards simplicity. That means organisational simplicity as well as product simplicity.

As I stated in my article “Simplicity, simplicity, simplicity“:

The inherent complexity of present-day smartphones risks all kinds of bad outcomes:

  • Smartphone device creation projects may become time-consuming and delay-prone, and the smartphones themselves may compromise on quality in order to try to hit a fast-receding market window;
  • Smartphone application development may become difficult, as developers need to juggle different programming interfaces and optimisation methods;
  • Smartphone users may fail to find the functionality they believe is contained (somewhere!) within their handset, and having found that functionality, they may struggle to learn how to use it.

In short, smartphone system complexity risks impacting manufacturability, developability, and usability.  The number one issue for the mobile industry, arguably, is to constantly find better ways to tame this complexity.

The companies that are successfully addressing the complexity issue seem, on the whole, to be the ones on the rise in the mobile space.

Footnote: It’s a big claim, but it may well be true that of all the books on the subject of innovation in the last 20 years, Clayton’s Christensen’s writings are the most consistently important.  The subtitle of his first book, “The innovator’s dilemma”, is a reminder why: “When new technologies cause great firms to fail“.

24 December 2009

Predictions for the decade ahead

Before highlighting some likely key trends for the decade ahead – the 2010’s – let’s pause a moment to review some of the most important developments of the last ten years.

  • Technologically, the 00’s were characterised by huge steps forwards with social computing (“web 2.0”) and with mobile computing (smartphones and more);
  • Geopolitically, the biggest news has been the ascent of China to becoming the world’s #2 superpower;
  • Socioeconomically, the world is reaching a deeper realisation that current patterns of consumption cannot be sustained (without major changes), and that the foundations of free-market economics are more fragile than was previously widely thought to be the case;
  • Culturally and ideologically, the threat of militant Jihad, potentially linked to dreadful weaponry, has given the world plenty to think about.

Looking ahead, the 10’s will very probably see the following major developments:

  • Nanotechnology will progress in leaps and bounds, enabling increasingly systematic control, assembling, and reprogamming of matter at the molecular level;
  • In parallel, AI (artificial intelligence) will rapidly become smarter and more pervasive, and will be manifest in increasingly intelligent robots, electronic guides, search assistants, navigators, drivers, negotiators, translators, and so on.

We can say, therefore, that the 2010’s will be the decade of nanotechnology and AI.

We’ll see the following applications of nanotechnology and AI:

  • Energy harvesting, storage, and distribution (including via smart grids) will be revolutionised;
  • Reliance on existing means of oil production will diminish, being replaced by greener energy sources, such as next-generation solar power;
  • Synthetic biology will become increasingly commonplace – newly designed living cells and organisms that have been crafted to address human, social, and environmental need;
  • Medicine will provide more and more new forms of treatment, that are less invasive and more comprehensive than before, using compounds closely tailored to the specific biological needs of individual patients;
  • Software-as-a-service, provided via next-generation cloud computing, will become more and more powerful;
  • Experience of virtual worlds – for the purposes of commerce, education, entertainment, and self-realisation – will become extraordinarily rich and stimulating;
  • Individuals who can make wise use of these technological developments will end up significantly cognitively enhanced.

In the world of politics, we’ll see more leaders who combine toughness with openness and a collaborative spirit.  The awkward international institutions from the 00’s will either reform themselves, or will be superseded and surpassed by newer, more informal, more robust and effective institutions, that draw a lot of inspiration from emerging best practice in open source and social networking.

But perhaps the most important change is one I haven’t mentioned yet.  It’s a growing change of attitude, towards the question of the role in technology in enabling fuller human potential.

Instead of people decrying “technical fixes” and “loss of nature”, we’ll increasingly hear widespread praise for what can be accomplished by thoughtful development and deployment of technology.  As technology is seen to be able to provide unprecedented levels of health, vitality, creativity, longevity, autonomy, and all-round experience, society will demand a reprioritisation of resource allocation.  Previous sacrosanct cultural norms will fall under intense scrutiny, and many age-old beliefs and practices will fade away.  Young and old alike will move to embrace these more positive and constructive attitudes towards technology, human progress, and a radical reconsideration of how human potential can be fulfilled.

By the way, there’s a name for this mental attitude.  It’s “transhumanism”, often abbreviated H+.

My conclusion, therefore, is that the 2010’s will be the decade of nanotechnology, AI, and H+.

As for the question of which countries (or regions) will play the role of superpowers in 2020: it’s too early to say.

Footnote: Of course, there are major possible risks from the deployment of nanotechnology and AI, as well as major possible benefits.  Discussion of how to realise the benefits without falling foul of the risks will be a major feature of public discourse in the decade ahead.

20 March 2009

The industry with the greatest potential for disruptive growth

Filed under: aging, healthcare, UKTA — David Wood @ 11:37 pm

Where is the next big opportunity?

According to renowned Harvard Business School professor and author Clayton Christensen, in a video recorded recently for BigThink:

The biggest opportunities are in healthcare. We are now just desperate to make healthcare affordable and accessible. Healthcare is something that everybody consumes. There are great opportunities for non-consumers to be brought into the market by making things affordable and accessible. I just can’t think of another industry that has those kinds of characteristics where demand is robust, and there’s such great opportunities for disruption.

The healthcare industry has many angles. I’m personally fascinated by the potential of smart mobile devices to play significant new roles in maintaining and improving people’s health.

Another important dimension to healthcare is the dimension of reducing (or even altogether removing) the impacts of aging. In an article on “10 ideas changing the world right now”, Time magazine recently coined the word “amortality” for the growing trend for people who seek to keep the same lifestyle and appearance, regardless of their physical age:

When Simon Cowell let slip last month that he planned to have his corpse cryonically preserved, wags suggested that the snarky American Idol judge may have already tested the deep-freezing procedure on his face. In 2007, Cowell, now 49, told an interviewer that he used Botox. “I like to take care of myself,” he said. Cowell is in show biz, where artifice routinely imitates life. But here’s a fact startling enough to raise eyebrows among Botox enthusiasts: his fellow Brits, famously unconcerned with personal grooming, have tripled the caseload of the country’s cosmetic surgeons since 2003. The transfiguration of the snaggletoothed island race is part of a phenomenon taking hold around the developed world: amortality.

You may not have heard of amortality before – mainly because I’ve just coined the term. It’s about more than just the ripple effect of baby boomers’ resisting the onset of age. Amortality is a stranger, stronger alchemy, created by the intersection of that trend with a massive increase in life expectancy and a deep decline in the influence of organized religion – all viewed through the blue haze of Viagra…

Amortals don’t just dread extinction. They deny it. Ray Kurzweil encourages them to do so. Fantastic Voyage, which the futurist and cryonics enthusiast co-wrote with Terry Grossman, recommends a regimen to forestall aging so that adherents live long enough to take advantage of forthcoming “radical life-extending and life-enhancing technologies.” Cambridge University gerontologist Aubrey de Grey is toiling away at just such research in his laboratory. “We are in serious striking distance of stopping aging,” says De Grey, founder and chairman of the Methuselah Foundation, which awards the Mprize to each successive research team that breaks the record for the life span of a mouse…

Notions of age-appropriate behavior will soon be relegated as firmly to the past as dentures and black-and-white television. “The important thing is not how many years have passed since you were born,” says Nick Bostrom, director of the Future of Humanity Institute at Oxford, “but where you are in your life, how you think about yourself and what you are able and willing to do.” If that doesn’t sound like a manifesto for revolution, it’s only because amortality has already revolutionized our attitudes toward age.

Just how feasible is the idea of radical life extension? In part, it depends on what you think about the aging processes that take place in humans. Are these processes fixed, or can they somehow be influenced?

One person who is engaged in a serious study of this topic is Dr Richard Faragher, Reader in the School of Pharmacy and Biomolecular Sciences at the University of Brighton on the English south coast. Richard describes the research interests of his team as follows:

We “do” senescence. Why do we do this? Because it has been suggested for over 30 years that the phenomenon of cell senescence may be linked in some way to human ageing. Senescence is the progressive replicative failure of a population of cells to divide in culture. Once senescent, cells exhibit a wide range of changes in phenotype and gene expression which give them the potential to alter the behaviour of any tissue in which they are found. In its modern form the cell hypothesis of ageing suggests that the progressive accumulation of such senescent cells (as a result of ongoing tissue turnover) may contribute to the ageing process.

Richard is the featured speaker at this month’s Extrobritannia (UKTA) meeting in Central London, this Saturday (21st March). The title for his talk is “One foot in the future. Attaining the 10,000+ year lifespan you always wanted?”:

Dr Richard Faragher, Reader in Gerontology, School of Pharmacy & Biomolecular Sciences, University of Brighton, will review the aging process across the animal kingdom together with the latest scientific insights into how it may operate. The lecture will also review promising avenues for translation into practice over the next few years, and current barriers to progress in aging research will be considered.

I’m expecting a lively but informative discussion!

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