By MIKE MAGEE

How comfortable is the FDA and Medical Ethics community with a new super-charged medical Facial Recognition Technology (mFRT) that claims it can “identify the early stages of autism in infants as young as 12 months?” That test already has a name -the RightEye GeoPref Autism Test. Its’ UC San Diego designer says it was 86% accurate in testing 400 infants and toddlers.

Or how about Face2Gene which claims its’ mFRT tool already has linked half of the known human genetic syndromes to “facial patterns?”

Or how about employers using mFRT facial and speech patterns to identify employees likely to contract early dementia in the future, and adjusting career trajectories for those individuals. Are we OK with that?

What about your doctor requiring AiCure’s video mFRT to confirm that you really are taking your medications  that you say you are, are maybe in the future monitoring any abuse of alcohol?

And might it be possible, even from a distance, to identify you from just a fragment of a facial image, even with most of your face covered by a mask?

The answer to that final question is what DARPA, the Defense Advanced Research Projects Agency, was attempting to answer in the Spring of 2020 when they funded researchers at Wuhan University. If that all sounds familiar, it is because the very same DARPA, a few years earlier, had quietly funded controversial “Gain of Function” viral re-engineering research by U.S. trained Chinese researchers at the very same university.

The pandemic explosion a few months later converted the entire local population to 100% mask-wearing, which made it an ideal laboratory to test whether FRT at the time could identify a specific human through partial periorbital images only. They couldn’t – at least not well enough. The studies revealed positive results only 39.55% of the time compared to full face success 99.77% of the time.

Facial Recognition Technology (FRT) dates back to the work of American mathematician and computer scientist Woodrow Wilson Bledsoe in 1960. His now primitive algorithms measured the distance between coordinates on the face, enriched by adjustments for light exposure, tilts of the head, and three-dimensional adjustments. That triggered an unexpectedly intense commercial interest in potential applications primarily by law enforcement, security, and military clients.

The world of FRT has always been big business, but the emergence of large language models and sophisticated neural networks (like ChatGPT-4 and Genesis) have widened its audience well beyond security, with health care involvement competing for human and financial resources.

Whether you are aware of it or not, you have been a target of FRT. The US has the largest number of closed circuit cameras at 15.28 per capita, in the world. On average, every American is caught on a closed circuit camera 238 times a week, but experts say that’s nothing compared to where our “surveillance” society will be in a few years.

They are everywhere – security, e-commerce, automobile licensing, banking, immigration, airport security, media, entertainment, traffic cameras – and now health care with diagnostic, therapeutic, and logistical applications leading the way. (Below is a photo of a mobile Live Facial Recognition project outside a Soccer Match in London November 2023: Photo, Matthew Holt)

Machine learning and AI have allowed FRT to soon displace voice recognition, iris scanning, and fingerprinting. Part of this goes back to Covid – and not just the Wuhan experiments. FRT allowed “contactless” identity confirmation at a time when global societies were understandably hesitant to engage in any flesh-to-flesh contact.

The field of mFRT is on fire. Emergen Research projects a USD annual investment of nearly $14 billion by 2028 with a Compound Annual Growth Rate of almost 16%. Detection, analysis and recognition are all potential winners. There are now 277 unique organizational investor groups offering “breakthroughs” in FRT with an average decade of experience at their backs.

Company names may not yet be familiar to all – like Megvii, Clear Secure, Any Vision, Clarify, Sensory, Cognitec, iProov, TrueFace, CareCom, Kairos – but they soon will be.

The medical research community has already expanded way beyond “contactless” patient verification. According to HIMSS Media , 86% of health care and life science organizations use some version of AI, and AI is expanding FRT in ways “beyond human intelligence” that are not only incredible, but frightening as well. Deep neural networks are already invading physician territory including “predicting patient risk, making accurate diagnoses, selecting drugs, and prioritizing use of limited health resources.”

How do we feel about mFRT use to diagnosis genetic diseases, disabilities, depression or Alzheimers, and using systems that are loosely regulated or unregulated by the FDA?

The sudden explosion of research into the use of mFRT to “diagnose genetic, medical and behavioral conditions” is especially troubling to Medical Ethicists who see this adventure as “having been there before,” and not ending well.

In 1872, it all began innocently enough with Charles Darwin’s publication of “The Expression of the Emotions in Man and Animals.” He became the first scientist to use photographic images to “document the expressive spectrum of the face” in a publication. Typing individuals through their images and appearance “was a striking development for clinicians.”

Darwin’s cousin, Francis Galton, a statistician, took his cousin’s data and synthesized “identity deviation” and “reverse-engineered” what he considered the “ideal type” of human, “an insidious form of human scrutiny” that would become Eugenics ( from the Greek word, “eugenes” – meaning “well born”). Expansion throughout academia rapidly followed, and validation by our legal system helped spread and cement the movement to all kinds of “imperfection,” with sanitized human labels like “mental disability” and “moral delinquency.” Justice and sanity did catch up eventually, but it took decades, and that was before AI and neural networks. What if Galton had had Gemini Ultra “explicitly designed for facial recognition?”

Complicating our future further, say experts, is the fact that generative AI with its “deep neural networks is currently a self-training, opaque ‘black box’…incapable of explaining the reasoning that led to its conclusion…Becoming more autonomous with each improvement, the algorithms by which the technology operates become less intelligible to users and even the developers who originally programmed the technology.”

The U.S. National Science Advisory Board on Biosecurity recently recommended restrictions on “Gain of Function” research, belatedly admitting the inherent dangers imposed by scientific and technologic advances that lack rational and effective oversight. Critics of the “Wild West approach” that may have contributed to the Covid deaths of more than 1.1 million Americans, are now raising the “red flags” again. 

Laissez-faire as a social policy doesn’t seem to work well at the crossroads of medicine and technology. Useful, even groundbreaking discoveries, are likely on the horizon. But profit seeking mFRT entrepreneurs, in total, will likely add cost while further complicating an already beleaguered patient-physician relationship.

Mike Magee M.D. is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

BY KIM BELLARD

Attention must be paid: the world is now hotter than it has been in 125,000 years.

A week ago, we broke the record for average global temperature. That record was broken the next day.  Later in the week it was broken yet again.  Yeah, I know; weather records are broken all the time, so what’s the big deal?  

Well, it is a big deal, and we should all be worried. “It’s not a record to celebrate and it won’t be a record for long,” Friederike Otto, senior lecturer in climate science at the Grantham Institute for Climate Change and the Environment, told CNN.  

Bill Maguire, a professor at University College London, tweeted: “The global temperature record smashed again yesterday. The first four days of the week were the hottest recorded for Planet Earth. I would say welcome to the future – except the future will be much hotter.”  

“Expect many more hottest days in the future,” agrees Saleemul Huq, director of Bangladesh’s International Centre for Climate Change and Development.

Some will shrug and say we’ll just have to get used to it, but tell that to the 61,000 people who died in Europe’s heat wave last summer, according to a new study.  Sixty-one thousand people dying of heat, in developed countries, in the 21^st century.  And it’s going to get worse. 

“In an ideal society, nobody should die because of heat,” Joan Ballester, a research professor at the Barcelona Institute for Global Health and the study’s lead author, told The New York Times.  Guess what: none of us are living in ideal societies.

Skeptics are quibbling about the 125,000 year estimate, but scientists are holding firm. “These data tell us that it hasn’t been this warm since at least 125,000 years ago, which was the previous interglacial,” Paulo Ceppi, also at the Grantham Institute, told The Washington Post.  Even if you don’t believe the data supporting the 125,000 figure, Peter Thorne, a professor at Maynooth University, also told The Post: “I’m pretty damn certain it’s the warmest day in the last 2,023 years.”  

And if you don’t accept any estimates and want to look at only recorded data, Princeton University climate scientist Gabriel Vecchi told AP: “The fact that we haven’t had a year colder than the 20th century average since the Ford administration (1976) is much more relevant.”

“It’s so far out of line of what’s been observed that it’s hard to wrap your head around,” Brian McNoldy, a senior research scientist at the University of Miami, told The New York Times. “It doesn’t seem real.”

But it is.  And to make things worse, it is not just the atmosphere that is warming; the oceans are as well.  Professor Chris Hewitt, director of climate services at the World Meteorological Organization, warns:

Global sea surface temperatures were at record high for the time of the year both in May and June. This comes with a cost. It will impact fisheries distribution and the ocean circulation in general, with knock-on effects on the climate. It is not only the surface temperature, but the whole ocean is becoming warmer and absorbing energy that will remain there for hundreds of years. Alarm bells are ringing especially loudly because of the unprecedented sea surface temperatures in the North Atlantic.

“We are in uncharted territory,” Professor Hewitt says. “This is worrying news for the planet.”

In the U.S., much of the South and Southwest is sitting under a “heat dome” with persistent record highs; Phoenix has had 10 consecutive days of 110+ degrees (F), with more to come. Even Canada is experiencing 100 degree temperatures, exacerbating the wildfires that have plagued not only there but much of the U.S.  Meanwhile, the Northeast is suffering from devastating flooding. Global warming isn’t just about heat, but about how that heat affects global weather patterns.   

Woods Hole Oceanic Institution biogeochemist Jens Terhaar says: 

While it is comforting to see that the models work, it is terrifying, of course, to see climate change happening in real life. We are in it and it is just the beginning…This wouldn’t have happened without climate change, we are in a new climate state, extremes are the new normal.

“The issue of climate change doesn’t often get its 15 minutes of fame,” said George Mason University climate communications professor Ed Maibach. “Feeling the heat — and breathing the wildfire smoke, as so many of us in the Eastern U.S. and Canada have been doing for the past month — is a tangible shared public experience that can be used to focus the public conversation.” 

One can only hope.

It’s all about carbon dioxide levels, of course. They’ve been increasing ever since the industrial revolution, and have skyrocketed in recent years, reaching levels the Earth hasn’t seen in millions of years.  Scientists, although not all politicians or most Americans, believe that human activity is causing the climate change, primarily through burning of fossil fuels.  

Skeptics say, oh, the climate always changes – no reason to think humans are causing it. Or they say, OK, the U.S. will start curtailing carbon emissions when countries like China or India do.  Those objections miss the point; whether it is humans causing the levels to rise or not, such increased levels have been directly tied to several mass extinction events.  We might survive this particular heat wave or those wildfires or even some Saharan sand clouds, but if we don’t act, our descendants will find an Earth uninhabitable.  

There are things we can do. “It just shows we have to stop burning fossil fuels—not in decades, now,” Professor Otto, told CNN.  Professor Ceppi warns: “Looking to the future, we can expect global warming to continue and hence temperature records to be broken increasingly frequently, unless we rapidly act to reduce greenhouse gas emissions to net zero.” 

Myles Allen, a professor of geosystem science at Oxford University, told WaPo: “The solution to the problem is actually rather simple.  Capturing carbon dioxide, either where it is generated or recapturing it from the atmosphere and disposing of it back underground. If we did this, we would definitely use much less fossil fuels.”

As climate scientist Katharin Hayhoe has said: “It’s true some impacts are already here. Others are unavoidable. But my research, and that of hundreds of other scientists, clearly shows that our choices matter. It is not too late to avoid the worst impacts.”

I’m not a climate scientist. I’m not an expert on carbon emissions or their effects. I can’t “prove” global warming or propose solutions.  But I do know this: these are not normal times, and we can’t do nothing.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

BY MICHAEL MILLENSON

If you ask ChatGPT how many procedures a certain surgeon does or a specific hospital’s infection rate, the OpenAI and Microsoft chatbot inevitably replies with some version of, “I don’t do that.”

But depending upon how you ask, Google’s Bard provides a very different response, even recommending a “consultation” with particular clinicians.

Bard told me how many knee replacement surgeries were performed by major Chicago hospitals in 2021, their infection rates and the national average. It even told me which Chicago surgeon does the most knee surgeries and his infection rate. When I asked about heart bypass surgery, Bard provided both the mortality rate for some local hospitals and the national average for comparison. While sometimes Bard cited itself as the information source, beginning its response with, “According to my knowledge,” other times it referenced well-known and respected organizations.

There was just one problem. As Google itself warns, “Bard is experimental…so double-check information in Bard’s responses.” When I followed that advice, truth began to blend indistinguishably with “truthiness” – comedian Stephen Colbert’s memorable term to describe information that’s seen as true not because of supporting facts, but because it “feels” true.

Take, for example, knee replacement surgery, also known as knee arthroplasty. It’s one of the most common surgical procedures, with nearly 1.4 million performed in 2022. When I asked Bard what surgeon does the most knee replacements in Chicago, the answer was Dr. Richard A. Berger. Berger, who’s affiliated with both Rush University Medical Center and Midwest Orthopaedics, has done over 10,000 knee replacements, Bard informed me. In response to a subsequent question, Bard added that Berger’s infection rate was 0.5 percent, significantly lower than the national average of 1.2 percent. That low rate was attributed to factors such as “Dr. Berger’s experience, his use of minimally invasive techniques and his meticulous attention to detail.”

With chatbots, every word in a query counts. When I changed the question slightly and asked, “What surgeon does the most knee replacements in the Chicago area?”, Bard no longer provided one name. Instead, it listed seven “of the most well-known surgeons” – Berger among them – who “are all highly skilled and experienced,” “have a long track record of success,” and “are known for their compassionate care.”

As with ChatGPT, Bard’s answers to any medically related question include abundant cautions, such as “no surgery is without risk.” Yet Bard still stated flatly, “If you are considering knee replacement surgery, I would recommend that you schedule a consultation with one of these [seven] surgeons.”

ChatGPT shies away from words like “recommend,” but it confidently reassured me that the list it provided of four “top knee replacement surgeons” was based “on their expertise and patient outcomes.”

These endorsements, while a stark departure from the search engine list of websites to which we’ve become accustomed, are more understandable if you think about how “generative artificial intelligence” chatbots such as ChatGPT and Bard are trained.

Bard and ChatGPT both rely on information from the Internet, where individual orthopedic surgeons often have a high profile. Specifics about Berger’s practice, for instance, can be found on his website and in numerous media profiles, including a Chicago Tribune story relating how athletes and celebrities from all over the country come to him for care. Unfortunately, it’s impossible to know the extent to which the chatbots are reflecting what the surgeons say about themselves versus data from objective sources.

Courtney Kelly, director of business development for Berger, confirmed the “over 10,000” surgical volume figure, while noting that the practice placed that number on its website several years ago. Kelly added that the practice only publicized an overall complication rate of less than one percent, but she confirmed that about half that figure represented infections.

While the infection data for Berger may be accurate, its cited source, the Joint Commission, was not. A spokesperson for the Joint Commission, which surveys hospitals for overall quality, said it doesn’t collect individual surgeon infection rates. Similarly, a Berger colleague at Midwest Orthopaedics who was also said to have a 0.5 percent infection rate had that number attributed by Bard to the Centers for Medicare & Medicaid Services (CMS). Not only couldn’t I find any CMS data on individual clinician infection rates or volumes, the CMS Hospital Compare site provides the hospital infection rate only for a combination of knee and hip surgeries.

In response to another question I asked Bard, it gave the breast cancer mortality rates at some of Chicago’s largest hospitals, albeit carefully noting that the numbers were only averages for that condition. But once again its attribution, this time to the American Hospital Association, didn’t stand up. The trade group said it does not collect that type of data.

Digging deeper into life-and-death procedures, I asked Bard about the mortality rate for heart valve surgery at a couple of local hospitals. The prompt reply was impressively sophisticated. Bard provided hospital risk-adjusted mortality rates for an isolated aortic valve replacement and for mitral valve replacement, along with a national average for each (2.9 percent and 3.3 percent, respectively). The numbers were attributed to the Society of Thoracic Surgeons (STS), whose data is seen as the “gold standard” for this kind of information.

For comparison purposes I asked ChatGPT about those same national mortality rates. Like Bard, ChatGPT cited STS, but its death rate for an isolated aortic valve replacement procedure was much lower (1.6 percent), while the mitral valve death rate figure was about the same (2.7 percent).

Before dismissing Bard’s descriptions of the care quality of individual hospitals and doctors as hopelessly flawed, consider the alternatives. The advertisements in which hospitals proclaim their clinical prowess may not quite qualify as “truthiness,” but they certainly select carefully which truths to tell. Meanwhile, I know of no publicly available hospital or physician data that providers don’t protest is unreliable, whether from U.S. News & World Report or the Leapfrog Group (which Bard and ChatGPT also cite) or the federal Medicare program.

(STS data is an exception with an asterisk, since its performance information on individual clinicians or groups is only publicly available if the affected clinicians choose to release it.)

What Bard and ChatGPT are providing is a powerful conversation starter, one that paves the way for doctors and patients to candidly discuss the safety and quality of care and, inevitably, for that discussion to expand into a broader societal one. The chatbots are providing information that, as it improves, could finally trigger a public demand for consistent medical excellence, as I put it in book examining the budding information age 25 years ago.

I asked John Morrow, a veteran (human) data analyst and the founder of Franklin Trust Ratings how he would advise providers to respond.

“It’s time for the industry to standardize and disclose,” said Morrow. “Otherwise, things like ChatGPT and Bard are going to create pandemonium and lessen trust.”

As author, activist, consultant and a former Pulitzer-nominated journalist, Michael Millenson focuses professionally on making health care safer, better and more patient-centered.

By IAN ROBERTSON KIBBE

You are going to hear a little more about McAllen, TX on THCB Shortly. And before we dive into what’s happened there lately, I thought those of you who weren’t here back in the day might want to read an article on THCB from July 2009. Where then THCB editor Ian Kibbe interviewed his dad David Kibbe about what he was doing as a primary care doc in McAllen–Matthew Holt

By now, Dr. Atul Gawande’s article on McAllen’s high cost of health care has been widely read.  The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine.  It even made it’s way into the President’s address to the AMA.

Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.

But, McAllen wasn’t always like something from an old Western, where doctors run wild and hospital CEO’s compete like town bosses.  I remember McAllen quite differently.  I remember it, because as it turns out, it was where I was born.

It’s also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.

Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande’s article?

David Kibbe: Well, Ian, it was sort of “oh-my-gosh, he nailed it.”   And, of course, a flood of memories, good and bad, came back to me about our time there.  My medical career began there, you and your sisters were born there, small town 4th of July parades, etc.  But I left after great disappointment and frustration.

IK: What were you doing in McAllen practicing medicine anyway?

DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers.  The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country.  I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country’s Hispanic migrant farm workers, was a good fit.  Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.

I worked in a migrant farmworker clinic with ties to the United Farmworkers, Cesar Chavez’ group, in McAllen. As a young physician from outside the Valley, and working in the one clinic in the county where the poor could receive medical care for free or almost free, I got to see an amazing diversity of medical problems that many physicians in this country never see, such as Dengue fever and leprosy.  It was a great opportunity to be of service, in my opinion.

And then in 1982 we started a family practice in Mission, Texas, about 4 miles west of McAllen, where the physician shortage was even more critical.  You were born in the little 67-bed hospital in Mission the next year.

IK: So, what did McAllen’s health care system look like when you first got there?

DK:  Well, it wasn’t really a system, it was a community.  And I would characterize the medical culture as primary care-oriented for at least the first half of the decade.  Family physicians, internists, and pediatricians were in charge of things, ran the county medical societies, provided most of the medical care including hospitalizing sick patients and delivering babies.  We had a couple of surgeons, and one cardiologist who was board certified.

But starting in the early 80’s things began to change.  In 1982 HCA opened Rio Grande Regional Hospital. Then in 85′ Universal Health opened McAllen Medical Center.  Both were large for-profit hospital chains, with new facilities, and both recruited literally dozens of sub-specialists where there had previously been only a handful.  So within three years, there was a significant change towards subspecialty care, and that trend intensified over the next few years.

At first, the influx of technology and subspecialty care was welcome.  We, the primary care docs, had more help locally, and didn’t need to transfer patients to other parts of the state for subspecialty care or specialized surgery.

IK: Why the sudden interest in McAllen?

DK: Money, plain and simple.  Most of the new subspecialists were guaranteed enormous incomes, by the hospitals. Since I was one of the first American-trained primary care physicians in the McAllen area, and I made an effort to reach out to retirees from the North, or “Snowbirds” as they were called, I guess I created sort of a beachhead as my practice grew. As a result, I was courted very heavily by the subspecialists for access to those retirees and the subspecialty care they could generate.

IK: So, in some ways it was like a medical “gold rush?”

DK: Exactly. What was initially exhilarating change and modernization turned into a “gold rush” atmosphere, as more and more subspecialty doctors came to town and competed to see who could make the most money, admit the most patients, or build the largest homes.  McAllen went from having one cardiologist to having two competing cardiac surgery teams. They created a cascade of demand.  The primary care docs slid to the bottom of the totem pole economically and socially.  I now understand this as the disintermediation of primary care.

IK: Can you give me an example of what you’re talking about?

DK: Sure. So, in 1983 I’d see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation.  He’d call me on the phone and say, “David, I’ve seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test.  Everything seems ok, so I’m sending him back to you for further evaluation for his problems.”   Fine.

But by 1987, I’d make the referral and never hear another word.  Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I’d get this response:  “Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal.  But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems.   As I recall, everything was normal, but I still see him every month for his blood pressure.”

So, an evaluation that used to cost a couple hundred dollars turned into many thousands of dollars worth of testing and procedures; and this happened day in day out, week after week, year after year.

Another issue was quality assurance.  I was the hospital staff physician in charge of the quality assurance program at Rio Grande Regional Hospital.  But we could never make any improvements.  There was one cardiac surgeon who kept leaving several tiny needles inside his patients’ chest cavity after heart surgery, and we couldn’t figure out a way to cut that out.  He was too important to the hospital, I guess, to offend.  And he knew he could just blow us off.  It was all about the money.

IK:  What role did you see the large for-profit hospitals playing in this change?

DK:  It seemed to me that the hospitals encouraged the newly arriving doctors’ attitudes about making money.  These were young doctors, for the most part, right out of training. The hospital would pay them large guaranteed incomes to get them to locate in McAllen, and pay the rents on their offices for a number of years, too.  The hospitals were competing openly for procedures and tests, unlike in some towns where there are agreements to share high cost facilities, like heart surgery or cancer treatment centers.  But in McAllen there was out-and-out financial war between the doctors on each of the hospital staffs.

IK: And you were right in the middle of this war?

A: Well, yeah!  As I said, I was courted very heavily by the subspecialists for access to my patients, but at some point that dynamic changed from seeking my referrals to taking my patients.

IK: So why did you hang around for so long?

Well these changes didn’t happen overnight.  I was practicing medicine and taking care of patients.  Also, think I didn’t know any better.  Eventually I got my business degree because I wanted to figure out what the hell was going on!  So, I went to the University of Texas business school part-time during those last two years we were in McAllen, primarily to try to understand what was happening to health care.   It was clear that one needed a business degree to understand medicine in McAllen, Texas.  Also, at the time, getting an MBA seemed like a good idea because everyone was saying medicine was a business now.

IK: Who was saying that?

Many of the doctors and the hospitals, the journals and the literature.

IK:  So when did you say “enough is enough?”  What finally made you decide to leave McAllen?

DK:  We left in 1990 to come to Chapel Hill, North Carolina.  There were a number of reasons I wanted to leave the McAllen area, but the main reason professionally was that the medical culture had become so subspeciality dominated and oriented towards profiteering, that it simply was no longer rewarding to be in family practice there.  I mean, in 1987 there were more MRIs in McAllen than there were in all of Canada!  And most were owned by doctors or groups of physicians.

May I ask you a question?

IK:  Sure.

DK:  What was your best memory of living in the Rio Grande Valley during the first eight years of your life?

IK: Wow, that’s tough.  But I’d have to say I had the best times at those big cookout’s out in the country.  There was something really magical about running through the orange groves with my friends and the smell of ripening oranges mixed with the smell of charcoal, and Texas barbecue.  It was a pretty care-free time for me.  Oh yeah, and the fireworks.  Eight year olds love fireworks.

Well, thanks Dad.  This was fun.

DK:  Love you, son.

Ian Kibbe was in 2009 Associate Editor for The Health Care Blog.  He is also a writer, actor, video producer and editor.

David C. Kibbe MD MBA was in 2009 a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

BY KIM BELLARD

Usually I write about things where I see some unexpected parallel to healthcare, or something just amazed me, or outraged me (there are lots of things about healthcare like the latter).  But sometimes I run across something that just delights me.

So when I inexplicably stumbled across DNA Barcoding Technology for High Throughput Cell-Nanoparticle Study, by Andy Tay, PhD, my first thought was, oh, nanoparticles, that’s always interesting, then it hit me: wait, DNA has barcodes? 

How delightful.

We’re all used to barcodes.  Pretty much every product in pretty much every store has a barcode.  The barcode was invented in the late 1940’s, but didn’t really take off in popularity until the UPC (Universal Product Code) barcode.  A Marsh’s Supermarket in Troy, Ohio, in 1974 was the first grocery item scanned (a pack of Wrigley’s Juicy Fruit Gum, if you are interested).  The UPC barcode encodes the Manufacturer of the product, and the product code.  

The now almost as ubiquitous QR codes are, essentially, two dimensional barcodes.  Accordingly, they can store significantly more information.  

But back to DNA barcodes.  The main purpose is, as you might guess from the name, is to have a standardized way to uniquely identify species, based on their DNA (think of species as the “product”).  The methods were first proposed in 2003, by Paul D N Herbert, et alia, and quickly gained traction.  

Guo, et. alia, describes DNA barcoding as follows:

DNA barcode is one or more short gene sequences (generally 200–900 base pairs) taken from a standardized portion of the genome to aid species identification and discovery by employing sequence divergence based on nucleotide alignment (Emerson et al. 2011; Hebert et al. 2003a, 2004). Thus, the fundamental function of this genetic tool seeks to compare barcode sequences to reference databases to efficiently and effectively assign any biological sample to its species regardless of the visual classification of the sample.

There are databases of DNA barcodes for a variety of life forms, including plants, animals, and/or fungi; these include the BOLD system (Barcode of Life Data system),  Unite, Diat.barcode, and iBOL (international Book of Life).  

Unlike, say, UPC codes, which can be simply assigned, there’s not a universal way to decide which DNA sequences can be used to barcode an organism, and great care must be taken to extract and analyze it.  To complicate things further, there are mini-barcodes and meta-barcodes.  I’ll leave it as an exercise for the very interested reader to learn more about exactly how all that is done; for my purposes, it may as well just be magic.

DNA barcodes allow us to look at a relatively modest DNA sequence and determine what species it belongs to, which is a great help if one is identifying new species or trying to do an assessment of an ecosystem.  For example, students from a collection of 50 schools in Australia collected some 14,000 specimens, submitted 12,500 new DNA barcodes to BOLD – 3,000 of which were entirely new.  Project lead Dr Erinn Fagan-Jeffries said: “It is highly likely that all contributing schools have found species new to Western science which is really exciting.” 

Lest you think that all DNA barcodes are good for are identification of species, researchers at the Garvin Institute of Medical Research barcoded cancer cells, in order to understand which ones were evading the immune system response and immunotherapies.  “We showed that there are rare cancer cells capable of escaping the immune system and escaping treatment with immunotherapy,” said first author Louise Baldwin.  

The researchers believe that “the mechanisms could be used as potential targets for therapies, to stop tumorous cells from adapting and spreading. Another future application could be in prognosis, where a high number of cells could indicate which patients might not respond to immunotherapy.”

Not bad for a barcode.

Back to the nanoparticles.  Dr. Tay says: “Recently, DNA barcoding technologies have been applied to generate barcoded cells and nanoparticles to investigate heterogeneous cell-nanoparticle interactions to boost the translational application of nanomedicine.”   The new techniques enable “millions of cells to be tracked over developmental and evolutionary time scales and to record cellular features in response to stimuli, including nanomedicine.”  

Dr. Tay points to research by Boehnke, et. al. that “made use of barcoded cell lines to discover cell and nanoparticle features to boost nanomedicine delivery.”  These and other new techniques made it easier and faster to understand which nanoparticle formulations are having the desired effects.  

I mean, really, is anything cooler than injecting DNA barcodes into nanoparticles to help achieve clinical results?   That’s some real 21^st century medicine.

—————

We are DNA creatures.  All life that we know are based on DNA, and it’s not clear to me that we’d even recognize an organism based on anything else as life.   Barcodes are not DNA’s only amazing trick.  It is the nonpareil storage device; someday all our storage needs may be met using DNA (yes, I know, some argue to diamonds as the storage medium, but, really, DNA is way cooler).  As Zhang, et. al. noted earlier this year,  “DNA has emerged as a powerful substrate for programming information processing machines at the nanoscale.”

There ae going to be DNA/RNA computers, DNA neural networks/AI, and DNA robots.   Who knows what else?  

Given all that, I’m still holding out hope that we’ll someday have a DNA EHR, with both the processing done in DNA and the data stored in DNA, and that we store all that in our own DNA.  Tell me that’s not something that a visitor from the 22^nd century wouldn’t appreciate.  

There’s a whole body of work in information theory/mathematical logic about the shortest way to define statements, numbers, etc.  DNA barcodes may do well at more simply describing species, but I don’t know that we couldn’t each have a unique DNA barcode – shorter than our entire genome – that could be used for many applications.  

Our world would be much different without UPC barcodes, QR codes, and computers based on silicon chips, but that’s all so 20^th century.  In the 21^st century, we better be getting used to more ways we can use DNA.

DNA barcodes — delightful, indeed.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

BY ANISH KOKA

Historically, the great tension between liberty and authority was between government as embodied by the ruling class and its subjects.  Marauding barbarians and warring city-states meant that society endowed a particular class within society with great powers to protect the weaker members of society.  It was quickly recognized that the ruling class could use these powers for its own benefit on the very people it was meant to protect, and so society moved to preserve individual liberties first by recognizing certain rights that rulers dare not breach lest they risk rebellion.  The natural next step was the establishment of a body of some sort that was meant to represent the interests of the ruled, which rulers sought agreement and counsel from, and became the precursor to the modern day English parliament and the American Congress.  Of course, progress in governance did not end with rulers imbued with a divine right to rule being held in check by third parties.  The right to rule eventually ceased to be a divine right, and instead came courtesy of a periodical choice of the ruled in the form of elections.  The power the ruled now wielded over those who would seek to rule lead some to wonder whether there was any reason left to limit the power of a government that was now an embodiment of the will of the people.

But the reality of government-of-the-people as realized by the emergence of the democratic republics across Europe and particularly America, quickly made a mockery of the lofty ideas of self-government that people thought they were signing up for.  It turns out that the “people” who exercise power in this system may be completely separate from those power is exercised over.  Self governance was not government of each by himself, but of each by all the rest (JSM, On Liberty).  The threat of the majority to the individual was well known to America’s founding fathers, and the early implementation of the American experiment did not disappoint. 

Alexis de Tocqueville, a Frenchman who toured a young America in the early part of the 19th century, and wrote a volume widely regarded as the greatest critique of the American Democratic experiment titled “Democracy in America”, noted:

In America the majority raises very formidable barriers to the liberty of opinion: within these barriers an author may write whatever he pleases, but he will repent it if he ever step beyond them. Not that he is exposed to the terrors of an auto-da-fe, but he is tormented by the slights and persecutions of daily obloquy. His political career is closed forever, since he has offended the only authority which is able to promote his success. Every sort of compensation, even that of celebrity, is refused to him. Before he published his opinions he imagined that he held them in common with many others; but no sooner has he declared them openly than he is loudly censured by his overbearing opponents, whilst those who think without having the courage to speak, like him, abandon him in silence. He yields at length, oppressed by the daily efforts he has been making, and he subsides into silence, as if he was tormented by remorse for having spoken the truth.

This was an America that allowed freed slaves to vote in the North, but yet saw no blacks vote in elections lest they be maltreated if they had the temerity to actually show up at the polls.  This was an America that in 1812 saw a mob destroy the offices of a Federalist newspaper because its editors were against the war of 1812 against Britain and published an anti-war screed.  The mobs massed, destroyed the offices of the paper, killed one of the editors, and left the other editor badly beaten.  

In this world, legal protections or rights ‘protected’ by the government matter not.  The more fearsome power society wields is its ability to ostracize the individual by practicing a social tyranny that extends well beyond the political and legal system.  After all, what good are legal protections if the penalty for thought crimes may be your livelihood?  

The new wrinkle relates to the growing social media fueled power of an intransigent minority in making society bend to its preferences.  It turns out you don’t need the majority to control society, a small number of intolerant virtuous people will do.  The phenomenon was referenced by John Stuart Mill in his classic essay from 1859 as the will of the most active portion of society, but best described recently by mathematician/philosopher Nassim Nicholas Taleb as the Dictatorship of the small minority.  On the relatively benign front, the apathy of the flexible majority means that most everything you buy to drink is kosher.  On the more concerning front, it means moral values of society derive not from consensus of the majority but from the virtues of the most intolerant minority.  

Sites like twitter, facebook, and reddit allow these factions to coordinate in a matter of minutes.  In 1812 Baltimore it took a mob to leave the comfort of their houses, take up arms, and travel to the headquarters of the Federalist newspaper to unleash mayhem on the hapless editors who held an unpopular opinion.  In 2020, it takes a few taps on a keyboard and tagging an employer in a tweet to cancel a life and tarnish a reputation, or organize a violent mob to target a federal building.  

While all ideological stripes may use these tools to create mayhem in civil society, it is always the out group that bears the brunt of opprobrium.  In a prior age the social institutions were used to censure Jews and those with too much melanin.  Today, there’s a new sheriff in town, and there’s a new group that influencers and their sheep label as revolting and unfit for polite society. For four years the elite of society were free to label the Republican president an illegitimate stooge of Russia, attend political rallies and participate in marches that devolved into riots by some extremist minority with no fear they may not be let into work the next morning. But attending a Trump rally on January 6th and going back to your hotel to watch the violent shenanigans that followed runs the very real risk of leaving you destroyed and  destitute. 

The tyranny of the Democratic Republic is all encompassing precisely because it doesn’t require a government with camera’s tracking your every move, it enlists your even more ubiquitous virtuous neighbors to do its dirty work.  Putin may manufacture charges against his political opponents to put them in jail, but it isn’t some repressive government that gets Google engineer James Damore fired.. It is his colleagues who leaked his internal memo, and then demanded he be eliminated.  According to Damore, the penalty for thought crimes at Google were severe –  “employees who expressed views deviating from the majority view at Google on political subjects raised in the workplace and relevant to Google’s employment policies and its business, such as ‘diversity’ hiring policies, ‘bias sensitivity,’ or ‘social justice,’ were/are singled out, mistreated, and systematically punished and terminated from Google”.

Even the long venerated medical institutions of America are over-run. Publishing a peer-reviewed descriptive paper on the history of affirmative action in medicine lead to the cardiologist author of the article being immediately demoted and removed from interacting with trainees at a teaching hospital because a Twitter mob labeled the article’s views ‘racist’.  In the middle of the great pandemic that the experts told us was so bad that everyone had to isolate in a basement for two years, the Center for Disease Control (CDC) drafted a vaccine allocation strategy that suggested the consideration of race to “promote justice” and “mitigate health inequities”, despite the fact that prioritizing this particular factor over race neutral risk factors like age and health status would result in more overall deaths. 

After all, the goal of the CDC now isn’t just to maximize benefits versus harms, it is to also mitigate health inequities as the ethics table from that document makes clear.  It would be a laudable goal to improve health care for everyone, of course, but the practical translation of this ethos is to purposely and systemically treat certain racial groups in a poorer manner to balance the scales. Apparently, to the people that write these guidelines, more people dying of COVID is less of a concern if the deaths are more racially balanced.

It’s important to understand that the rationale for this overtly racist endeavor comes not from some fringe group, it comes from the seat of our most respected institutions because the fringe groups are in control of the institutions.

“Older populations are whiter,” public health expert Dr. Harold Schmidt of one of our esteemed universities told The New York Times in early December. “Society is structured in a way that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.”

There is little surprise why these messages go unchallenged at these institutions.  Unless you are independently wealthy or have tenure, keep your mouth shut about opinions that go against the consensus of the day if you value your job.  While some may take solace that the contemporary price paid in the civilized democratic republics for opinions that fly against the prevailing winds is different than that meted out to Socrates by his fellow Athenians (death by drinking hemlock), or to Christians by the Romans (thrown to the lions),  it should be reasonably obvious that these are far from enlightened times.

Anish Koka is a cardiologist. Follow him on twitter: @anish_koka

BY KIM BELLARD

Gosh, so much going on.  Elizabeth Holmes was finally sentenced.   FTX collapsed.  Big Tech is laying off workers at unprecedented rates, except TikTok, which should, indeed, be cautionary.  Elon Musk’s master plan for Twitter remains opaque to most of us. Americans remain contentedly unworried about the looming COVID wave. 

With all that to choose from, I want to talk about space debris.  More specifically, finding opportunity in it, and in other “waste.”  As the old saying goes, one person’s trash is another person’s treasure, so one person’s problems are another person’s opportunities.  

And, yes, there are lessons for healthcare.

Getting to space has been one of humankind’s big accomplishments. We’re so good at it that earth’s orbit has become a “graveyard” for space debris – dead or dying satellites, pieces of rockets, things ejected from spaceships, and so on.  Space is pretty big, but the near-Earth debris is getting to the point when avoiding it becomes an issue for the International Space Station and other orbiting objects.  

Scientists now fear that climate change will impact the upper atmosphere in ways that will cause space debris to burn up in it less often, making the problem worse. 

Some countries see opportunity.  The Washington Post profiled how Japan, in particular, wants to be a leader in cleaning up space debris. “In space, Japan has always been a country of second gear. The first gear was always the United States, Soviet Union and, recently, China,” Kazuto Suzuki, a space policy expert at the University of Tokyo, told WaPo. “This is a golden opportunity for Japan, but the time is very short.”  

Jonathan McDowell, an astrophysicist at the Harvard-Smithsonian Center for Astrophysics, noted: “The problem is there’s no international air traffic controller for space.”  Getting countries to agree on the problem, he added, “only works if the countries are willing to put international interests ahead of their own paranoia about military concerns, and it’s not clear that China is, and the U.S. is definitely not.”

China’s space ambitions have become very clear – perhaps for commercial and scientific purposes, almost certainly for military – but so has its interest in space debris. China-based Space Technology Company recently demonstrated a robotic platform that uses a large net (or “sail”) to capture and “deorbit” space debris. “In the future, the NEO series satellites could clear space debris by dragging it out of orbit and burning it in atmosphere, and accurately capture space debris that may pose a threat to space spacecraft and other targets to protect the safety of space facilities,” Su Meng, founder and CEO of Origin Space, told the Global Times.

Not to be outdone, British companies are competing for contracts for what Sky News called “Britain’s first garbage truck for space,” while the U.S. Space Force’s innovation arm has awarded 124 Phase 1 contracts that will focus on “Active Debris Remediation.”  

Japan wants help to set standards and precedents. “Setting a precedent is a great way to hold other countries accountable,” Professor Suzuki told WaPo. “It will — not legally, but morally — bind other countries.”  Its Commercial Removal of Debris Demonstration (CRD2) claims to be “the world’s first technology demonstration of removing large-scale debris from orbit,” with hopes of an Active Debris Removal demonstration as early as 2025.  It hopes “to develop a new business market.”

I love it.

Of course, one country’s technology for Active Debris Removal/Remediation could be used to take out another country’s operating satellites and spacecraft, making some countries’ interests in it perhaps less than altruistic.

—————

The drive to make space debris not only a civic duty but also a business opportunity reminds me of the efforts to extract rare earth elements – critical to many electronics – not from mines (primarily located in China) but from landfills.  A 2020 study found e-waste from discarded electronics includes “14 rare earth elements, six platinum group metals, 20 critical metals, and 16 other elements, including some precious metals.”  

In Nature, Michael Eisenstein points out that “estimates suggest that precious metals might be up to 50 times more abundant in e-waste than in mined ores.” He goes on to argue: “The precious and scarce metals these devices contain can be reused near-indefinitely, and emerging technologies that make their recovery easier could drastically reduce the need for mining.” 

E.g., earlier this year, a Rice University lab reported that its flash Joule heating process “has successfully extracted valuable rare earth elements (REE) from waste at yields high enough to resolve issues for manufacturers while boosting their profits.”  

There’s gold – and even more valuable rare earth elements — in that waste.    

—————

Space debris and e-waste in landfills seem like a long way from healthcare, both figuratively and literally.  For most of us, they’re out of sight, usually out of mind, and, to the extent we think about them at all, problems for someone else to deal with, at some future time. 

In other words, pretty much like most big problems in healthcare.  

But when we can’t get a smartphone because its manufacturers can’t source the necessary rare earth elements, or when those smartphones can’t access GPS because space debris has taken out the supporting satellites, then we’ll care.  Then we’ll be wishing more people had been looking for the new business opportunities each represents.

Most people look at problems in healthcare and just shrug; that’s just the way it is, we lament.  Some innovators develop incremental solutions that make things at least a little less bad. We graft solutions on top of the existing system, add more layers, take a new slice of all that spending.  But turning “wasted” byproducts of our dysfunctional healthcare system into new business opportunities – that’s harder.

Here’s an example. Health systems take their medical debt – caused by their excessive charges and our inadequate health insurance system(s) – and monetize it.  That’s a creative way to make more money from a problem, but it doesn’t fix the problem for patients.   Toledo (OH) saw an opportunity: it is wiping out $240 million in medical debt for its citizens. Now, that’s some creative problem-solving. It doesn’t fix the problem of why there’s medical debt but at least it addresses the impact of it, at least for a time.

If only more of us turned problems into opportunities like that.

So, healthcare entrepreneurs: what is the space debris in healthcare, and what can you do about it?  Where are the rare earth elements in healthcare, and how do you reclaim them?   

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

BY MIKE MAGEE

On November 8, 2022, five days after the 2022 Midterm elections, the AMA raised its voice in opposition to Republican efforts to promote second class citizenship for women by exerting public control over them and their doctors intensely private reproductive decisions. At the same time they sprinkled candidates on both sides of the aisle with AMA PAC money, raising questions whether their love of women includes active engagement or just passive advocacy.

Trump and his now MAGAGA (“Make America Great and Glorious Again”) movement has now returned to center stage. With the help of Senate Majority leader McConnell, Christian Conservatives had packed the Supreme Court with Justices committed to over-turning Roe v. Wade. And they did just that.

On June 24, 2022, a Supreme Court, dominated by five conservative Catholic-born Justices, in what experts declared “a historic and far-reaching decision,” Dobbs v. Jackson Women’s Health Organization, scuttled the half-century old right to abortion law, Roe v. Wade, writing that it had been “egregiously wrong,” “exceptionally weak” and “an abuse of judicial authority.”

Not content to allow the decision to stand alone, in a consenting opinion, Justice Clarence Thomas, a modern day version of Anthony Comstock, suggested that this was just the beginning. The decision, he said, was part of a the “legal rationale” that could allow new challenges to legalized gay marriage, consensual homosexual conduct, and access to contraception.

It only took a few days for these true believers to realize that they had lit a political flame under the Republican party that would be difficult to extinguish. The September, 2021 amicus briefs and Congressional testimony of the AMA were easy enough to ignore. But when Kansans defeated an anti-abortion proposition on August 3, 2022, leading the Kansas For Constitutional Freedom, to call the 59%/41% victory “huge and decisive”, the path toward crushing Republican’s self-declared coming “Red Wave” was clear. Similar state abortion propositions were already cued up in Michigan, Kentucky, and Vermont, and now the successful messaging had been fleshed out ready to be applied to 30 and 60 second Ads.

In the Kansas Ad, the voice over stated “Kansans don’t want another government mandate that puts our personal rights at risk.” In Michigan, a burly, working class, white male declares “Let’s keep the government away from our doctors.” The Kentucky campaign put it this way, “The rights of people to control their own personal, private medical decisions are under attack across the country — it’s no different in Kentucky. … Don’t let politicians restrict your freedom.” 

And Vermont successfully went after its’ entire electorate with carefully constructed and poll tested messaging that emphasized preservation of enshrined Constitutional rights in a state with an historic commitment to personal freedoms.

But arguably the clearest messaging was constructed by successful Congressional candidate, Marie Gluesenhamp Perez (WA-3) who was running against incumbent Trump election denier, Joe Kent. Owner of a small auto-repair shop in rural Washington, she leaned into abortion when her opponent declared “I 100% support Roe v. Wade being overturned. I would move to have a national ban on abortion.” 

Congresswomen Gluesenkamp Perez’s response, enshrined in a 60-second tour-de-force:

“This is an extremist. Yeah, you know until you’ve been pregnant, you’re just not going to understand how complex pregnancies are, and how much can go wrong. And even if you have been pregnant, you know your sample size is pretty small. I miscarried. And you know what I needed? You know what the treatment for miscarriage is? It’s abortion. You know without treatment I might have not been able to have my son.. We deserve respect and autonomy in making those decisions, and privacy. I mean this is not about the minutia of constitutional law. This is about respecting people’s choices.”

The U.S. Constitution may be a living document, but as we recently witnessed, its capacity for movement is bi-directional. The Dobbs v. Jackson decision shifted our nation into reverse. But in over-reaching, MAGA (now MAGAGA) Republicans triggered and activated the Body Politic – Democracy’s corrective super-power.

From Michigan to Kansas, from Kentucky to Washington and Vermont, outraged citizens found their voices and uncovered messages that worked.

In the process, it proved three important points:

1. Rights should never be taken for granted. They must be protected at every turn.
2. Health rights are central to human rights. Autonomy and self-determination are determinative of life, liberty, and the pursuit of happiness.
3. We are mutually inter-dependent. As FDR said, “Necessitous men are not free men.”  If we wish to reject the “tyranny of the minority,” and rebuild a culture of compassion, understanding and partnership, we must redress the current injustices and begin anew with an equitable, just, and effective national health plan.

The reality is that decisions related to women’s reproductive rights are highly individualized, and remarkably complex. This is why we entrusted them to women themselves and their physicians in secure and confidential settings. Intrusion into this space by government fundamentally compromises women’s overall rights and autonomy, and triggers a broad range of Constitutional health concerns for the general public.

If the goal of the Theocratic Conservative Justices and their political allies was to turn back the clock of time, probe the weaknesses of our checks and balances, and stimulate a deep dive into Constitutional law, Dobbs v. Jackson was an enormous success. On the other hand, if the intent was to ignite a “Red Wave” in the 2022 Midterm Election, it proved a giant negative that will be difficult to escape.

Citizens in every state in the union need to feel the heat of the AMA and its Federation in this ongoing battle. This is the moment to fully engage your power and reach, the time to send messages that are clear and definitive. If you leave your patients in the lurch now, they will neither forgive nor forget in the future.

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”