wrong diagnosis

Billionaires say they’ll end disease. Evolution suggests otherwise

The element of evolutionary time can be lost on technologists who think that more data and money will end disease.

In late 2016, Facebook’s CEO Mark Zuckerberg and his wife Priscilla Chan pledged to invest at least $3 billion to ‘cure, manage and prevent all disease’ through the creation of a Biohub, a fount of non-profit innovation that would retain the exclusive right to commercialise its inventions. Around the same time, Microsoft said it had plans to ‘solve’ cancer by 2026 and Facebook’s co-founder Sean Parker promised $250 million (through his tax-exempt non-profit organisation, or 501c3) to fight cancer while retaining the right to patents. The philanthropists Eli Broad and Ted Stanley have contributed $1.4 billion in private wealth to fund the Broad Institute research centre (another 501c3, involved in a high-stakes patent battle) and its associated Stanley Center for Psychiatric Research, to open ‘schizophrenia’s black box’ and hack the genetics of psychiatry. Much like Andrew Carnegie and John D Rockefeller of yesteryear, who donated their wealth to build public libraries and establish foundations, today’s Silicon Valley billionaires seek a legacy, this time in the realm of health and disease.

But there is a disconnect. The idea of the body as analogous to a machine, complete with bugs to be fixed by means of gene modification tools such as Crispr-Cas9, conflicts with Charles Darwin’s theory of evolution: machines and computers do not evolve, but organisms do. Evolution matters here because bits of code that compromise one function often enhance a second function, or can be repurposed for a new function when the environment shifts. In evolution, everything is grasping for its purpose. Parts that break down can become the next best thing.

The element of evolutionary time can be lost on technologists who think that more data and money will end disease. For Darwin, evolution of a species depended on natural selection of the individual organism. Discovery of DNA later resulted in what became known as the ‘modern synthesis’, establishing a unifying framework for the influence of tiny things such as genes and large things such as populations, all while preserving Darwin’s key principle that selection hinged on the individual. By 1966, the evolutionary biologists Richard Lewontin and John Hubby had proposed the concept of ‘balancing selection’, which suggests that rare versions of genes can stay in a population since they add to genetic diversity. In fact, being heterogeneous, or having a single copy of a rarer form of a gene, even one that is suboptimal or contributes to genetic risk, can often benefit an individual, thus remaining among a species in small frequencies.

Statue of Charles Darwin at the Natural History Museum London. (Photo: Patche99z/Wikimedia Commons)
Statue of Charles Darwin at the Natural History Museum London. (Photo: Patche99z/Wikimedia Commons)

The theoretical biologist Stuart Kauffman argued that rare genetic variants are the basis of innovation, and may remain in circulation, not by chance, but because they add a fitness benefit to the system of at least a small number of organisms in a population. ‘Evolution is not just “chance caught on a wing”. It is not just a tinkering of the ad hoc, of bricolage, of contraption. It is emergent order honoured and honed by selection,’ he wrote in The Origins of Order (1993).

By contrast, a modern data scientist often assumes the reductionist position: that more data and better analysis in biology will lead to problems solved. As the molecular biologist James Watson said in 1989: ‘We used to think that our fate was in our stars, but now we know that, in large measure, our fate is in our genes.’ One reason we might favour this explanation is that our brains are wired to seek answers, simple cause-effect relationships. But we have so few drugs and solutions nearly two decades after sequencing the human genome. This might have less to do with the quality of analysis and more to do with the biological principles of evolution and time. Instead of thinking of humanity as a closed system, we’d do better to look through the open lens of ecology, in which the system itself is subject to influence by input from the outside. In even a single lifetime, our bodies take on an onslaught of genetic mutations, hundreds of trillions of synaptic connections rewire our brains by the moment, and pathogens bombard us, penetrating the organs and blood-brain barrier, and creating an ever-changing microbiome that enhances or erodes health.

Disease an an evolving entity

In evolution, nothing comes for free. Stress can both trigger creativity and compound a raft of chronic maladies. Genetic variants that cause cystic fibrosis can protect against cholera, and those that contribute to Tay-Sachs can protect against tuberculosis. A variant in the gene PCSK9 can lower your LDL cholesterol, but can increase your risk for ischemic stroke. Gene transfer can effectively treat diseases caused by a single errant gene, but risk variants that influence diseases won’t go away because they often provide advantages as time goes on.

Even cancer is less a machine with cell circuits that go haywire than an evolving entity that undergoes evolution and change in real time. Shapeshifting tricks that enable a cancer to escape our treatment can be independent of changes to the permanent genetic code. One of the reasons that the immunotherapeutic approach has been so practical is that it treats cancer in terms of ecology. The cancer evolves, but the immune system, primed for that kind of fight, can sometimes keep pace.

Darwin introduced a viewpoint that was radically unsettling: we don’t progress to a more perfect form, but adapt to local environments. If humans are machines, then we can simply repair the broken parts. But if there is something more fundamental to the crisis of life than mere mechanisms of biology, then risk, and an element of danger, will always be with us. I will wager something even more: since genetic variation is the basis of innovation, and diversity, making ourselves too perfect could mean our doom.

The author is a science writer and computational biologist based in Cambridge, Massachusetts.

This article was first published on Aeon.

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What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.