This piece originally appeared in the Timmerman Report.
I make a lot of lists. It’s not the right approach for everyone, but it works for me, especially when there’s a lot going on in my life. Sometimes the lists are things to do, things to buy, or just ways to organize my thoughts. And yet my life isn’t particularly complicated or hard. When I dig into our healthcare system and how convoluted it can be, I’m thankful that I don’t have a lot of decisions to make or choices to research.
That’s not the case for everyone. For people with chronic diseases like diabetes or complicated conditions like cancer, being sick imposes not just health and financial burdens, but mental ones as well. Disease can force patients to make huge numbers of mentally taxing, difficult decisions every day.
As an example, a type 1 diabetic has to perform a daily balancing act. Every day she needs to estimate how much insulin she’ll need at different times depending upon what she’s doing now and what she’s planning for the near future. She also has to estimate how glycemic her foods are at every meal and whether her last insulin dose was enough. She’ll need to take into account other factors that may affect her metabolism. And the penalty for not getting it right? In mild cases, hypoglycemia, with attendant nausea, fuzzy thinking or blurred vision; or hyperglycemia, which incrementally increases her odds of long-term complications like neuropathy or cardiovascular issues. In severe cases, a patient can slip into a diabetic coma. On top of that, patients experience shame when being judged by their medical practitioners for not keeping their HbA1c levels under control.
That’s a mental burden.
Imagine that’s your life every day. Likely a good fraction of people reading this (about half, according to the CDC) don’t have to imagine it because they have a chronic condition. Now, many of those conditions are low maintenance and not greatly mentally taxing—for example, mild hypertension can be controlled with simple daily medication. But some conditions are more challenging and for people with multiple conditions, the mental gymnastics increase as different, and sometimes conflicting, medical decisions must be made.
It’s tough. It also reminds me of another systemic problem in our society. Having a chronic condition is a lot like living in poverty. Maybe there’s a way for the biopharma industry to catch several fish in one net by finding ways to help people manage their lives to better outcomes. And I think it would end up making real, financial sense to boot.
Let me back up a second. I’m not saying poverty and chronic disease are the same thing, or come from the same cause, or can be treated using all the same tools. There’s a limited amount any one tool or solution can do to help. But there’s a parallel there that I’d like to explore.
One of the many difficult things about poverty is continually being faced with hard, complex, mentally taxing decisions. The current Federal Poverty Level (FPL) is $24,300 for a family of four. Just a hair over $2,000 a month in income. In King County, Washington, where I live, about 10% of the population is at or below the FPL. When a family makes that little, every decision is important and can be a choice between bad and worse. How much should they spend on food versus utilities versus transportation to work? Getting to work might require multiple bus routes that don’t always arrive on time as well as figuring out how to make sure kids are taken care of before and after school. Even simple things like buying basic goods are made more difficult.1 If a family is unfortunate enough to be homeless, there’s the added burden of figuring out where to stay each night, how to keep track of their possessions.2
The financially secure don’t face the same problems; they have greater resources. They own cars, hire nannies, get Amazon grocery delivery to their doorstep. The very well off can hire advisors, experts, helpers who can do the heavy mental work of identifying options, weighing evidence, tailoring a solution to a specific person’s situation, environment, resources and needs. It’s been well reported that Steve Jobs did a number of extraordinary things in his attempts to stave off cancer, including having his genome sequenced and flying to Tennessee to get a liver transplant, and needless to say that’s not something most people can do.
So how to alleviate that mental burden? I think one solution would be a kind of simple, easy to use tool—a guide that would anticipate and organize, find and collate needed information in real time, respond to requests and reduce stress and mistakes. Imagine a smart, versatile primary care physician who can help you find the best specialist for your situation, help navigate the insurance process, and even help you organize your electronic health data and prepare the best questions for your doctor visit. Given the complexity of what we’re talking about, it’s almost like a wilderness guide.
It would be a bot.
This isn’t one of those things that travels through the internet collecting email addresses. The term can also refer to a somewhat autonomous piece of code that helps people get information they need through a flexible interface.
This concept is beginning to pop up in many places. Microsoft, Apple, Amazon, Google and Facebook all have versions of simple, voice or text activated bots that help people find the information they need when they want it. Many smaller players do as well. IBM seems to be leveraging Watson toward health-related apps. A continual goal in personal tech development is reducing the friction in getting and using information, and doing this by moving to more free-flowing flexible interfaces. Reading through reviews of the bots out there now shows that, while quite useful, they all have a long way to go. And that’s why there’s an opportunity for biopharma.
The typical bot being developed for the mass market is built to be broad but shallow. Its designers want it to have a ready answer for the most common questions that its general user base might pose. Such as, for example, how to get to that hot restaurant that just opened, while checking if it has open seating at 9—or to be able to order detergent and Oreos with a simple request. So, rather than competing in that arena, biopharma would take the opposite tack of creating agents that are very specialized in knowledge and go deep.
Poverty and chronic disease share the characteristics of complexity, of daily decisions that are highly dependent upon intricate knowledge of systems (healthcare, human services). Decisions are also highly individual. Both chronic disease and poverty require agents that are a cut above in terms of their artificial intelligence (AI)—but at the same time, since the field of expertise is narrower, the challenge is manageable.
Imagine that, instead of having to calculate your insulin dose, you text into your bot, “I’m having the teriyaki salmon at the Cheesecake Factory.” The bot knows when you had your last dose and what it was—possibly because it’s hooked up into a smart dosing pen—looks up the Cheesecake Factory menu information, correlates your activity with your Fitbit and texts back, “take 30 units.”
Or, as you’re taking the bus home from your job, your bot figures where you are based on GPS, your timeframe for getting home for dinner, the current bus schedules from the Metro real time database, and suggests you have time to stop at the grocery store where a special on diapers would save you 25%, and also finds an online coupon for an additional 10%. And then tells you where to go to catch the quickest bus to get you home after that.
You can see what I’m getting at.
You might ask why a biopharma company would want to get into this area, which at first glance might seem pretty far out of the typical drug development paradigm. And it is. But let me give you a few reasons why.
First, the classical drug development business model is coming up against some hard pushback in the form of pricing pressure and lagging productivity. Even though approvals of new drugs have seen an uptick in recent years, many of those drugs either are targeted toward small populations or are struggling to gain traction against generic competition. Alternative models for profit need to be explored, and wellness and disease management are natural next steps. Just as software as a service has begun to change how software companies get revenue, so might wellness services provide a different kind of revenue stream for biopharma. Bots like the kind I’ve described could be a big part of this area.
Second, there’s expertise. While there’s a new wave of ideas and talent coming from Silicon Valley into healthcare, there’s a big need among those players for familiarity with the regulatory and development environment around health. Biopharma companies can provide that, along with access to the patients and key opinion leaders needed to create the database of behaviors and algorithms that would feed into a behavior bot.
Third, let’s talk about reputation—which is where poverty comes in. These kinds of tools could, with a different knowledge base, be used by people living in poverty who struggle in decision-making due to lack of information. Could biopharma companies partner with human services agencies to make these tools available to underserved populations? And in doing so help wipe a little of the tarnish off of their reputation? It wouldn’t be a complete work of charity either. Ideas, design improvements and methods that are learned in helping the poor could be translated into similar tools for populations with chronic diseases.
I realize the connection to poverty is a stretch, but I don’t think it’s too far off base. Helping people to change behavior is one of the fundamental challenges of our time and a body of psychological research suggests having to make difficult, mentally taxing decisions reduces our ability to make good choices over the course of the day (although see this for a suggestion that maybe this isn’t quite the case). The environment around health, the delivery of health, and the place of medicines within that system are all undergoing some dramatic shifts. The forward looking biopharma will be trying to get ahead of that, so it doesn’t arrive in the future and find someone else got there first.
1Here I have to refer to one of my favorite passages from Men at Arms by Terry Pratchett. The protagonist, a humble police officer, is musing about the unfairness of economics and why the poor stay poor and the rich stay rich:
“The reason that the rich were so rich, Vimes reasoned, was because they managed to spend less money.
Take boots, for example. He earned thirty-eight dollars a month plus allowances. A really good pair of leather boots cost fifty dollars. But an affordable pair of boots, which were sort of OK for a season or two and then leaked like hell when the cardboard gave out, cost about ten dollars. Those were the kind of boots Vimes always bought, and wore until the soles were so thin that he could tell where he was in Ankh-Morpork on a foggy night by the feel of the cobbles.
But the thing was that good boots lasted for years and years. A man who could afford fifty dollars had a pair of boots that’d still be keeping his feet dry in ten years’ time, while the poor man who could only afford cheap boots would have spent a hundred dollars on boots in the same time and would still have wet feet.
This was the Captain Samuel Vimes ‘Boots’ theory of socioeconomic unfairness.”
2Soapbox time: One of the things that has come to bother me more about the debate surrounding poverty is the argument that people in poverty should just go to school, learn a new trade, work harder, and they could bootstrap themselves to a higher pay grade. I ask: with what time and with what funds? The companies looking into life extension have figured out that the most important resource for most people is time. We all want more time (preferably in a healthy state). If you’re at the poverty line, it’s so much harder to find the time and resources to allow you to take enough courses to help you find a better-paying career.