Saving Lives by Stripping the Power of Doctors
Clayton M. Christensen is a professor of business administration at the Harvard Business School. He is the bestselling author of five books, including his seminal work, The Innovator's Dilemma, which received the Global Business Book Award for the best business book of the year, and most recently, The Innovator's Prescription, which examines how to fix our healthcare system. Christensen serves on several public and privately traded boards and is the founder of a successful consulting company and an investment management firm. He holds a B.A. with highest honors in economics from Brigham Young University and an M.Phil. in applied econometrics and the economics of less-developed countries from Oxford University, where he studied as a Rhodes Scholar; he received an MBA with high distinction from the Harvard Business School in 1979, graduating as a George F. Baker Scholar, and was awarded his DBA from the Harvard Business School in 1992.
Topic: Bringing Disruptive Innovation to Healthcare
Christensen: A good way to visualize how disruptive innovations transform an industry is if you think of the geography of an industry as a set of concentric circles.
I’m Clayton Christensen, the Robert and Jane Cizik Professor of Business Administration at the Harvard Business School.
Question: How can disruptive innovation transform healthcare?
Christensen: The advent of sophisticated healthcare technology in the form of surgical suites and advanced imaging equipment and these big high speed multi-channel blood testing and analytical equipment has driven a centralization of the healthcare industry, so we have to take the patients to the hospital rather than to bring the solution to the problem. Now, do you think hospitals will ever become cheap by competing against each other? No. They’ll actually become more expensive. So what we need to do is drive the disruptive decentralization of the healthcare industry and we do that by bringing technology to outpatient clinics, so you can begin doing there the simplest of the things that within the past required a hospital and then keep driving that technology so that they can do more and more and more sophisticated things in that setting. And then we bring technology to doctor’s offices so they can begin doing the simplest of the things that previously had to be referred to a more expensive clinic and then drive that technology so that you can do in the doctors' office more and more the things that were required at the higher cost clinic. And then use technology to drive care to the home. And in a similar way, do you think healthcare will become cost effective if we just expect doctors to take pay cuts? That will never happen but instead we need to bring technology to physicians assistants and nurse practitioners so that they can begin doing the simplest of things that previously required a doctor and then drive that technology so that they can do more and more of those things. In other words, it’s by enabling lower cost venues of care and lower cost caregivers to become more and more capable of doing more remarkable things. That’s the mechanism by which healthcare becomes affordable not by expecting the expensive ones to become cheap.
Question: What specific innovations are most vital to the future of healthcare?
Christensen: Personal electronic medical records are very important to the future of healthcare. The challenge that we have to confront is care has to be coordinated and the reason why care has to be coordinated is there are interactions amongst drugs which if one provider prescribes a patient to take one set of drugs and another provider prescribes a different set for different disorders, those two things might interact in the patient’s body in really adverse ways and create real problems. One provider needs to know what other providers have previously done, so that we know whether or not a patient responded to a therapy so that we don’t duplicate tests and so on. Electronic medical records are really very important to assure that the right care is delivered to the right people without duplication or contradiction. In the past, a doctor could provide all of that coordination. The problem is there are so many more drugs now and so much more is known about how these drugs interact with each other and the system is fragmented enough that coordinating a patient’s care is actually beyond the cognitive ability of the world’s smartest doctors. They simply cannot keep in their mind a coordinated picture of all of the possible interactions and all of the possible sequences of care that all of their patients are experiencing. The only way to do it is to have the coordination be done by an information technology system where information about these issues is brought together and algorithms exist that will flag for the doctor and for the patient where there are problems or where there are experiences in the past from which we can learn. So these records are really very important. I think the perception in Washington of the state of digital medical records is very skewed. What they see is the patient with the doctor in the doctor’s office and the doctor continuing to write prescriptions on paper and keep the records on paper but that’s kind of the equivalent in telecom of the last 50 feet of the last mile and that indeed hasn’t been well-digitized, but 97% of all transactions and activities in the healthcare systems already are digitized and so the drug companies, the pharmacies, pharmacy benefit managers, insurance companies, everything they do is digitized. The major healthcare systems like Kaiser Permanente or Intermountain Health, Geisinger or here in the Boston area Partners, their activities are all digitized. So 97% of the data is already there. The problem is that as a natural first step in creating these electronic systems, the systems are not yet compatible. So each company has its own system and that’s a very natural first step. Now, we need technology that virtualizes the interface that enables the systems to talk to each other. That’s the problem and it will just take a little bit of time but it’s been solved in many other contexts. So it used to be that financial records were kept by different companies in different formats but they were able to ultimately virtualize those records so that all of us have a single place we can go to get our credit score even though the inputs come from many different people. This will happen.
Question: Are any low-cost technologies transforming the industry?
Christensen: There are a lot of wonderful devices that are simple and affordable that is driving the decentralization of healthcare. One set of devices have come a Seattle based company called SonoSite and from GE Medical Systems and this a little handheld ultrasound, a piece of ultrasound equipment. Now, if you ask the radiologist who has a very expensive Philips cart-based ultrasound system, these little handheld devices are just really crummy, don’t have anywhere near the functionality that the big system has. But if instead you bring that handheld system to the primary care physician or a nurse practitioner who is doing your annual physical exam, you know, in the past, the only way they could sense what was going on in the body was to feel for it or to listen for it with the test stethoscope and you give this people this little handheld ultrasound equipment, and my goodness, now they can look inside your body and do so much better a job at identifying nasant problems that might be emerging. And so at the periphery, at the distributed end of this disruptive decentralization, we’re bringing much greater capability to be more precise in the practice of medicine. The very same technology tried to deliver in the middle of the circle actually compromises quality. So that’s just one example. Let’s see…. other examples are the ability to determine whether you're pregnant or not, the ability to measure how quickly your blood clots. Point of care diagnostics are distributing the ability to figure out what’s gone wrong too a much larger population of people who can then act on that without the advise or direction of the experts in the middle.
Business strategist Clayton Christensen argues that nurse practitioners and retail health outlets should have increased authority in treating patients.
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Humans may have evolved to be tribalistic. Is that a bad thing?
- From politics to every day life, humans have a tendency to form social groups that are defined in part by how they differ from other groups.
- Neuroendocrinologist Robert Sapolsky, author Dan Shapiro, and others explore the ways that tribalism functions in society, and discuss how—as social creatures—humans have evolved for bias.
- But bias is not inherently bad. The key to seeing things differently, according to Beau Lotto, is to "embody the fact" that everything is grounded in assumptions, to identify those assumptions, and then to question them.
Ancient corridors below the French capital have served as its ossuary, playground, brewery, and perhaps soon, air conditioning.
- People have been digging up limestone and gypsum from below Paris since Roman times.
- They left behind a vast network of corridors and galleries, since reused for many purposes — most famously, the Catacombs.
- Soon, the ancient labyrinth may find a new lease of life, providing a sustainable form of air conditioning.
Ancient mining areas below Paris for limestone (red) and gypsum (green).Credit: Émile Gérards (1859–1920) / Public domain
"If you're brave enough to try, you might be able to catch a train from UnLondon to Parisn't, or No York, or Helsunki, or Lost Angeles, or Sans Francisco, or Hong Gone, or Romeless."
China Miéville's fantasy novel Un Lun Dun is set in an eerie mirror version of London. In it, he hints that other cities have similar doubles. On the list that he offhandedly rattles off, Paris stands out. Because the City of Light really does have a twisted sister. Below Paris Overground is Paris Underground, the City of Darkness.
Most people will have heard of the Catacombs of Paris: subterranean charnel houses for the bones of around six million dead Parisians. They are one of the French capital's most famous tourist attractions – and undoubtedly its grisliest.
But they constitute only a small fragment of what the locals themselves call les carrières de Paris ("the mines of Paris"), a collection of tunnels and galleries up to 300 km (185 miles) long, most of which are off-limits to the public, yet eagerly explored by so-called cataphiles.
The Grand Réseau Sud ("Great Southern Network") takes up around 200 km beneath the 5th, 6th, 14th, and 15th arrondissements (administrative districts), all south of the river Seine. Smaller networks run beneath the 12th, 13th, and 16th arrondissements. How did they get there?
Paris stone and plaster of Paris
It all starts with geology. Sediments left behind by ancient seas created large deposits of limestone in the south of the city, mostly south of the Seine; and gypsum in the north, particularly in the hills of Montmartre and Ménilmontant. Highly sought after as building materials, both have been mined since Roman times.
The limestone is also known as Lutetian limestone (Lutetia is the Latin name for ancient Paris) or simply "Paris stone." It has been used for many famous Paris landmarks, including the Louvre and the grand buildings erected during Georges-Eugène Haussmann's large-scale remodelling of the city in the mid-19th century. The stone's warm, yellowish color provides visual unity and a bright elegance to the city.
The fine-powdered gypsum of northern Paris, used for making quick-setting plaster, was so famed for its quality that "plaster of Paris" is still used as a term of distinction. However, as gypsum is very soluble in water, the underground cavities left by its extraction were extremely vulnerable to collapse.
Like living on top of a rotting tooth: subsidence starts far below the surface, but it can destroy your house.Credit : Delavanne Avocats
In previous centuries, a road would occasionally open up to swallow a chariot, or even a whole house would disappear down a sinkhole. In 1778, a catastrophic subsidence in Ménilmontant killed seven. That's why the Montmartre gypsum quarries were dynamited rather than just left as they were. The remaining gypsum caves were to be filled up with concrete.
The official body governing Paris down below is the Inspection Générale des Carrières (IGC), founded in the late 1770s by King Louis XVI. The IGC was tasked with mapping and, where needed, propping up the current and ancient (and sometimes forgotten) mining corridors and galleries hiding beneath Paris.
A delightful hiding place
Also around that time, the dead of Paris were getting in the way of the living. At the end of the 18th century, their final destination consisted of about 200 small cemeteries, scattered throughout the city — all bursting at the seams, so to speak. There was no room to bury the newly dead, and the previously departed were fouling up both the water and air around their respective churchyards.
Something radical had to happen. And it did. From 1785 until 1814, the smaller cemeteries were emptied of their bones, which were transported with full funerary pomp to their final resting place in the ancient limestone quarries at Tombe-Issoire. Three large and modern cemeteries were opened to receive the remains of subsequent generations of Parisians: Montparnasse, Père-Lachaise, and Passy.
The six million dead Parisians in the Catacombs, from all corners of the capital and across many centuries, together form the world's largest necropolis — their now anonymized skulls and bones methodically stacked, occasionally into whimsical patterns. The Catacombs are fashioned into a memorial to the brevity of life. The message above the entrance reads: Arrête! C'est ici l'empire de la Mort. ("Halt! This is the empire of Death.")
That has not stopped the Catacombs, accessible via a side door to a classicist building on the Avenue du Colonel Henri Rol-Tanguy, making just about every Top 20 list of things to see in Paris.
An underground economy
However, while the Catacombs certainly are the most famous part of the centuries-old network beneath Paris, and in non-pandemic times draw thousands of tourists each day, they constitute just 1.7 km (1 mile) of the 300-km (185-mile) tunneling total.
Subterranean Paris wasn't just used for mining and storing dead people. In the 17th century, Carthusian monks converted the ancient quarries under their monastery into distilleries for the green or yellow liqueur that still carries their name, chartreuse.
Because the mines generally keep a constant cool temperature of around 15° C (60° F), they were also ideal for brewing beer, as happened on a large scale from the end of the 17th century until well into the 20th century. Several caves were dug especially for establishing breweries, and not just because of the ambient temperature: going underground allowed brewers to remain close to their customers without having to pay a premium for real estate up top.
Overview of the Paris Catacombs.Credit: Inspection Générale des Carrières, 1857 / Public domain.
At the end of the 19th century, the underground breweries of the 14th arrondissement alone produced more than a million hectoliters (22 million gallons) per year. One of the most famous of Paris' underground breweries, Dumesnil, stayed in operation until the late 1960s.
In that decade, the network of corridors and galleries south of the Seine, long since abandoned by miners, became the unofficial playground for the young people of Paris. They explored the fantastical world beneath their feet, in some cases via entry points located in their very schools. Fascinated, these cataphiles ("catacomb lovers") read up on old books, explored the subterranean labyrinth, and drew up schematics that were passed around among fellow initiates as reverently as treasure maps.
As Robert Macfarlane writes in Underland, Paris-beneath-their-feet became "a place where people might slip into different identities, assume new ways of being and relating, become fluid and wild in ways that are constrained on the surface."
Some larger caves turned into notorious party zones: a 7-meter-tall gallery below the Val-de-Grâce hospital is widely known as "Salle Z." Over the last few decades, various other locations in subterranean Paris have hosted jazz and rock concerts and rave parties — like no other city, Paris really has an "underground music scene."
Hokusai's Great Wave as the backdrop to the "beach" under Paris.Credit: Reddit
Cataphiles vs. cataphobes
With popularity came increased reports of nuisance and crime — the tunnels provided easy access to telephone cables, which were stolen for the resale value of their copper.
The general public's "discovery" of the underground network led the city of Paris to officially interdict all access by non-authorized persons. That decree dates back to 1955, but the "underground police" have an understanding with seasoned cataphiles. Their main targets are so-called tourists, who by their lack of knowledge expose themselves to risk of injuries or worse, and degrade their surroundings, often leaving loads of litter in their wake.
The understanding does not extend to the IGC. Unlike in the 19th century, when weak cavities were shored up by purpose-built pillars, the policy now is to inject concrete to fill up endangered spaces — thus progressively blocking off parts of the network. That procedure has also been used to separate the Catacombs to prevent "infiltration" of the site by cataphiles.
Many subterranean streets have their own names, signs and all. This is the Rue des Bourguignons (Street of the Burgundians) below the Champs des Capucins (Capuchin Field), neither of which exists on the surface.Credit: Jean-François Gornet via Wikimedia and licensed under
The cataphiles, however, are fighting back. In a game of cat and mouse with the authorities, they are reopening blocked passages and creating chatières ("cat flaps") through which they can squeeze into chambers no longer accessible via other underground corridors.
Catacomb climate control
Alone against the unstoppable tide of concrete, the amateurs of Underground Paris would be helpless. But the fight against climate change may turn the subterranean labyrinths from a liability into an asset — and the City of Paris into an ally.
The UN's 2015 Climate Plan — concluded in Paris, by the way — requires the world to reduce greenhouse gas emissions by 75 percent by 2050. And Paris itself wants to be Europe's greenest city by 2030. More sustainable climate control of our living spaces would be a great help toward both targets. A lot of energy is spent heating houses in winter and cooling them in summer.
This is where the constant temperature of the Parisian tunnels comes in. It's not just good for brewing beer; it's a source of geothermal energy, says Fieldwork, an architectural firm based in Paris. It can be used to temper temperatures, helping to cool houses in summer and warming them in winter.
One catch for the cataphiles: it also works when the underground cavities are filled up with concrete. So perhaps one day, Paris Underground, fully filled up with concrete, will completely fall off the map, reducing the city's formerly real doppelgänger into an air conditioning unit.
Cool in summer, warm in winter: Paris Underground could become Paris A/C.Credit: Fieldwork
Strange Maps #1083
Got a strange map? Let me know at firstname.lastname@example.org.
"Deepfakes" and "cheap fakes" are becoming strikingly convincing — even ones generated on freely available apps.
- A writer named Magdalene Visaggio recently used FaceApp and Airbrush to generate convincing portraits of early U.S. presidents.
- "Deepfake" technology has improved drastically in recent years, and some countries are already experiencing how it can weaponized for political purposes.
- It's currently unknown whether it'll be possible to develop technology that can quickly and accurately determine whether a given video is real or fake.
After former U.S. President William Henry Harrison delivered his inaugural speech on March 4, 1841, he posed for a daguerreotype, the first widely available photographic technology. It became the first photo taken of a sitting American president.
As for the eight presidents before Harrison, history can see them only through artistic renderings. (The exception is a handful of surviving daguerreotypes of John Quincy Adams, taken after he left office. In his diary, Adams described them as "hideous" and "too true to the original.")
But a recent project offers a glimpse of what early presidents might've looked like if photographed through modern cameras. Using FaceApp and Airbrush, Magdalene Visaggio, author of books such as "Eternity Girl" and "Kim & Kim," generated a collection of convincing portraits of the nation's first presidents, from George Washington to Ulysses S. Grant.
Modern Presidents George Washington https://t.co/CURJQB0kap— Magdalene Visaggio (@Magdalene Visaggio)1611952243.0
What might be surprising is that Visaggio was able to generate the images without a background in graphic design, using freely available tools. She wrote on Twitter:
"A lot of people think I'm a digital artist or whatever, so let me clarify how I work. Everything you see here is done in Faceapp+Airbrush on my phone. On the outside, each takes between 15-30 mins. Washington was a pretty simple one-and-done replacement."
Ulysses S Grant https://t.co/L1IGXLI3Vl— Magdalene Visaggio (@Magdalene Visaggio)1611959480.0
"Other than that? I am not a visual artist in any sense, just a hobbyist using AI tools see what she can make. I'm actually a professional comics writer."
Did another pass at Lincoln. https://t.co/PdT4QVpMbn— Magdalene Visaggio (@Magdalene Visaggio)1611973947.0
Of course, Visaggio isn't the first person to create deepfakes (or "cheap fakes") of politicians.
In 2017, many people got their first glimpse of the technology through a video depicting former President Barack Obama warning: "We're entering an era in which our enemies can make it look like anyone is saying anything at any point in time." The video quickly reveals itself to be fake, with comedian Jordan Peele speaking for the computer-generated Obama.
While deepfakes haven't yet caused significant chaos in the U.S., incidents in other nations may offer clues of what's to come.
The future of deepfakes
In 2018, Gabon's president Ali Bongo had been out of the country for months receiving medical treatment. After Bongo hadn't been seen in public for months, rumors began swirling about his condition. Some suggested Bongo might even be dead. In response, Bongo's administration released a video that seemed to show the president addressing the nation.
But the video is strange, appearing choppy and blurry in parts. After political opponents declared the video to be a deepfake, Gabon's military attempted an unsuccessful coup. What's striking about the story is that, to this day, experts in the field of deepfakes can't conclusively verify whether the video was real.
The uncertainty and confusion generated by deepfakes poses a "global problem," according to a 2020 report from The Brookings Institution. In 2018, the U.S. Department of Defense released some of the first tools able to successfully detect deepfake videos. The problem, however, is that deepfake technology keeps improving, meaning forensic approaches may forever be one step behind the most sophisticated forms of deepfakes.
As the 2020 report noted, even if the private sector or governments create technology to identify deepfakes, they will:
"...operate more slowly than the generation of these fakes, allowing false representations to dominate the media landscape for days or even weeks. "A lie can go halfway around the world before the truth can get its shoes on," warns David Doermann, the director of the Artificial Intelligence Institute at the University of Buffalo. And if defensive methods yield results short of certainty, as many will, technology companies will be hesitant to label the likely misrepresentations as fakes."
Meconium contains a wealth of information.
- A new study finds that the contents of an infants' first stool, known as meconium, can predict if they'll develop allergies with a high degree of accuracy.
- A metabolically diverse meconium, which indicates the initial food source for the gut microbiota, is associated with fewer allergies.
- The research hints at possible early interventions to prevent or treat allergies just after birth.
The prevalence of allergies arising in childhood has increased over the last 50 years, with 30 percent of the human population now having some kind of atopic disease such as eczema, food allergies, or asthma. The cause of this increase is still subject to debate, though it has been associated with a number of factors, including changes to the gut microbiomes of infants.
A new study by Canadian researchers published in Cell Reports Medicine may shed further light on how these allergies develop in children by examining the contents of their first diaper.
The things you do for science
The research team examined the first stool of 100 infants from the CHILD Cohort Study. The first stool of an infant is a thick, green, horrid-looking substance called meconium. It consists of various things that the infant ingests during the second half of gestation. Additionally, it provides not only a snapshot of what the infant was exposed to during that time, but it also reveals what the food sources will be for the initial gut bacteria that colonize the baby's digestive tract.
The content of the meconium was examined and found to contain such varied elements as amino acids, lipids, carbohydrates, and myriad other substances.
A graph of the comparative, summed abundance of different elements in a metabolic pathway after scaling to median abundance of each metabolite. The blue figures are those children without atopy, the yellow ones show the data for those with an atopic condition. Petersen et al.
The authors fed this information into an algorithm that used this data, along with the identities of the bacteria present as well as the baby's overall health, to predict which infants would go on to develop allergies within one year. The algorithm got it right 76 percent of the time.
A way to prevent childhood allergies?
Infants whose meconium had a less diverse metabolic niche the initial microbes to settle in the gut were at the highest risk of developing allergies a year later. Many of these elements were associated with the presence or absence of different bacterial groups in the digestive system of the child, which play an increasingly appreciated role in our overall health and development. The findings were summarized by senior co-author Dr. Brett Finlay:
"Our analysis revealed that newborns who developed allergic sensitization by one year of age had significantly less 'rich' meconium at birth, compared to those who didn't develop allergic sensitization."
The findings could be used to help understand how allergies form and even how to prevent them. Co-author Dr. Stuart Turvey commented on this possibility:
"We know that children with allergies are at the highest risk of also developing asthma. Now we have an opportunity to identify at-risk infants who could benefit from early interventions before they even begin to show signs and symptoms of allergies or asthma later in life."
A model for early childhood allergies
Petersen et al.
As shown above, the authors constructed a model of how they believe metabolites and bacterial diversity help prevent allergies. Increased diversity of metabolic products in the meconium encourage the development of "healthy" families of bacteria, like Peptostreptococcaceae, which in turn promote the development of a healthy and diverse gut microbiome. Ultimately, such diversity decreases the likelihood that a child will develop allergies.