Can Japan Solve Its Population Problems with Robots?

 Japan's population is about to tank, and with it, will fall the world's second largest economy. In roughly 100 years, the country's population will decrease from 127 million to 44 million. The outlook is bleak, as birth rates are at an all-time low, and the country maintains the highest proportion of senior citizens in the world. By 2050, the Japanese workforce could decrease by as much as 70%. An entertaining segment on Current TV explored both the cause of, and a possible solution to, Japan's population catastrophe.

 Japanese couples are not having babies. As more and more Japanese women and men prioritized their career ambitions over starting families, the national birth rates plummeted. Inadequate child care and employer discrimination of working mothers further discouraged working couples from having children. Swallowed up in the "work hard, play hard" pace of big cities like Tokyo (not to mention all the pretty faces at the local Host/Hostess Clubs), the Japanese 30-somethings claim they're now too set in their ways to consider having kids.

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So if they're aren't enough children to run Japan's future economy, what about letting more people into the country? Could allowing more immigrants to enter Japan boost the country's future population and workforce? Not likely, if current trends hold true, as less than 2% of Japan's population was born outside of the country.  For those that make it through the immigration process, life is far from charmed. In Japan, immigrants are often viewed as second-class citizens -- they lack basic civil rights, cannot vote, and are mostly tasked with menial manual labor jobs.

So what's left? Children are out -- the Japanese aren't even having sex, let alone children (the average number of sexual encounters per person in Japan is half the number in the US.). Foreign workers don't seem to be a solution either; in fact, immigration reform in Japan might be a tougher battle than health care reform in the United States! Japan's best guess: robots. Seriously, robots? Why not just throw jet-packs, flying cars, and tele-porters into the solution while we're at it? But it turns out, the Japanese may be on the right track. Japanese scientists have created new human-like robots that not only express emotion, but recognize it as well. Visionaries see the vast potential of these robots -- from primary caregiver roles where they help out with grandma's housework, to running the front desk at the DMV.

One Japanese scientist even created a robot in his own likeness. He figures this way, he can exist in multiple places at once. Gone will be the days when his wife complains of him spending too much time in the lab. Now he can send his robot to substitute for him at...err...home, so he can continue his important lab work uninterrupted. Seriously. Watch the video...

Will Keas Live Up To Its Potential?

"The human body does enormously well healing itself," Keas founder, and ex-Google Health lead, Adam Bosworth told Health 2.0 conference-goers shortly after stepping on stage.  On the heels of an article in the New York Times that touted the company's beta launch, Bosworth walked the crowd through the way we'll keep ourselves healthy in the future, using Keas' platform.

Over the past few years, Bosworth carefully watched as the Health 2.0 revolution unfolded. Medical issues became less of a private experience.  People, who at one time only discussed personal ailments with their family physician, now turned to family and trusted friends for medical advice.  With the boom of the Internet, a person's trusted medical community suddenly became infinite.

Of all people, Bosworth understood the potential power of the internet on health, where the collective wisdom of the patient population could reach thousands, or millions, of other people.  So he wondered, if people were readily turning to the web for information when they got sick, could customized, preemptive web advice keep people from getting sick in the first place?

Keas' system uses custom "Care Plans" that collect personal data that the user either uploads at the website, or is transferred directly from a lab, like Quest Diagnotics.  Keas plans to run its own iPhone-like App Store, where doctors or other health care providers create their own Care Plans, integrate them into the Keas platform, and instantly distribute them to millions of people.

By personalizing the measures we can take to stave off certain predisposed conditions, Keas' Care Plans should improve our health.  But the real promise of the company, wasn't in what Bosworth delivered onstage, but rather, in something he simply mentioned in passing.  Bosworth alluded to the idea that not only will Keas' platform let people track their own health, but it could also allow people to keep tabs on their family's health as well.

Imagine logging into your Keas profile, and being presented with a dashboard that shows the current health information for your spouse, child, and elderly parent.  Did your husband get his blood work test today?  How much has your child exercised?  Has your 80-year-old father read the online information packet on "Preventing Falls in the Home"?  At a glance, you'd have this information in front of you on the Keas website, if the company follows through with this idea.

When people become chronically ill, or simply start living into their eighties and nineties, maintaining health shifts from an individual to a team sport.  There's too much information for one person to process and comprehend.  Too many medications.  Too many things to keep straight.  Current estimates put 30 million people in the US as primary caregivers -- adults, aged 18 or over, who maintain the personal well-being of another adult.  Keas' program has the potential to make the term "long-distance caregiver' obsolete.  Everyone would be just a click away from checking-in with their loved ones.

Smart Screening & Dumb Screening

The big news of the day on my radar is the news that the American Cancer Society is cautioning that there may be a thing as too much screening, particularly for prostate and breast cancers. The New York Times has the story. The ACS's recommendation is based on the work of Dr. Laura Esserman, a professor of surgery and radiology at the University of California, San Francisco, and Dr. Ian Thompson, professor of urology at The University of Texas Health Science Center, San Antonio. The killer quote: “We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of the cancer society. “But I’m admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.”

I've had the opportunity to hear both of these researchers speak, and they are smart eggs - and I'm thrilled that their work is getting such coverage. Dr. Thompson's work, for instance, is discussed in my forthcoming book (This is one of those stories that I'm thrilled to see, on the one hand, because it dovetails so neatly with what's in the book - while also a little chagrined to see, as an idea in the book gets wide currency before the book is out!).

Screening tests are one of the great tools of public health, where we can detect disease before it makes itself known. But there's a distinction between what I call "dumb screening" and "smart screening." Dumb screening is the idea that, given the tools, medicine should root out cancer whereever it lurks in whatever form, no matter the cost (to the psyche or the pocketbook). Smart screening, on the other hand, is the growing notion that all cancers are not the same; that there are some that are lethal and some that are not, and what we need to do is deploy the right tools to spot the right cancers. It's a more delicate task, and a more difficult judgment to make. But really, it's the path of all science - moving away from simplicity and towards complexity.

In many situations, screening works. Some 30,000 children in the United States have been spared mental retardation because of PKU testing. A blood test used to screen for colon cancer—the second-deadliest form of cancer for men and women overall, even though, ironically, it’s among the easiest to screen for—has been shown to save as many as 10,000 lives in the United States annually. These are the sorts of results that make people evangelize about a new screening test, because it allows the possibility of changing the future, of plucking people off one course and setting them on another that promises a longer, healthier life.

And screening is only going to get more common for three reasons. First is the emphasis on preventive medicine, based on the recognition by the medical establishment and the US government that having an earlier warning saves lives and money. Second are an emerging class of risk-based conditions like metabolic syndrome and high cholesterol that bring with them a new checklist of routine tests. The third driver is technology itself: New proxies for proximity, such as CT scans and PET scans, give us a look deep inside the human body. These are tempting tools for screening large numbers of people for diseases that are otherwise invisible. Genetic tests, which skip over the imaging of our bodies and go straight to the molecular level of our cells, are another driver for implementing more screening tests.

If these technologies are deployed systematically and wisely, they can be a great boon to our health, both collectively and individually. But the fact is that screening tests aren’t always used wisely. Though a screening test can be the first step in a well-considered Decision Tree, a screening test without forethought can propel us into a zone of ambiguous probabilities and poorly calibrated risks.

In the case of prostate cancer, in particular, there's been a growing sense that screening has downsides that outweigh the benefits. One noteworthy approach is taken by a startup called Soar BioDynamics. Soar sells a decision-support tool for men who’re trying to make sense of their PSA test results. The idea is to discern what, exactly, besides cancer could produce a high PSA level, so men don’t move too quickly toward biopsy and removal, with all the latter’s  egative consequences. Using the information from a man’s PSA test along with that from a few other easy tests and data points, Soar’s tool calculates the most likely scenarios for what’s happening inside a man’s body, ranging from an enlarged prostate, to an infection, to a lethal cancer. The calculations are presented as probability scores for diagnoses.

“We can cut way down on the false positives and eliminate detection of the cancers that aren’t progressing. You want to catch the bad stuff, but ignore the stuff you don’t need to know about,” says company founder Tom Neville. “The issue isn’t just what decisions you make, but what order you make them in. We’re trying to switch the order of events. There’s all this stuff driving people toward biopsy and treatment. We’d like to eliminate the unnecessary biopsies and only go to the expensive experts when it’s highly warranted. We’re not trying to do away with screening. The PSA test can be a valuable test, there’s a lot of information in there. But it’s important to know what the test actually shows.”

Soar charges for its service—$80 for one year of reports. But there are other, free tools out there that take a similar approach, turning research around so an individual can interrogate it for its applicability to his specific circumstances, rather than having to navigate through stacks of research papers and findings for some wisp of relevance. At the University of Texas at San Antonio, Dr. Thompson has developed a prostate risk calculator that lets a man enter his PSA level along with his age, race, family history, and a couple of other metrics and churns out his risk of developing prostate cancer. Importantly, the calculator also calculates the risk of a high-grade cancer, accounting for the fact that not all prostate cancers are lethal. The value of such a tool, Thompson said at a recent symposium hosted by the Canary Foundation, is that it turns the PSA figure from one isolated data point into one of many inputs. “We need to build in characteristics about the person, their age, their race, their family history,” says Dr. Thompson. “It’s not just what one test tells us.”

For a play-by-play look at how scientists trying to distinguish between smart screening and dumb screening, see my story on the Canary Foundation from Wired.

To Get Rid of the Diseases Mosquitoes Carry, Feed the Bugs Bacteria

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I saw this study in Science at the beginning of the month, and a summary was posted at The Scientist:

A bacterium that infects insects may provide a biological method for stunting the spread of a range of devastating human diseases. The bacteria may protect their hosts against disease-causing pathogens by hiking up the insects' immune response, according to a study published online today (October 1) in Science.

Basically, mosquitoes were fed a certain bacteria, called "popcorn" Wolbachia, that did two things, 1.) boosted the immune system of the mosquitoes, which made them less likely carriers of diseases such as filarial nematodes (cause lymphatic filariasis), and 2.) cut the average lifespan of the mosquitoes in half.

Researchers are looking at the future possibilities of this promising treatment -- a natural way to curb the dangerous infectious diseases spread by mosquitoes.  Questions remain whether the "popcorn" bacteria could also interfere with the mosquitoes' ability to carry more dangerous diseases, such as malaria or the Dengue virus.

The Reward System Actually Reduces Motivation? Really?

I just wanted to offer a rebuttal to the following tweet that popped up on my stream today:

@GuyKawasaki The reward system actually reduces motivation http://om.ly/MHzl

First, let's take a look at the cited study.  The experimental groups were defined as:

The children were then randomly assigned to one of the following conditions:

1. Expected reward. In this condition children were told they would get a certificate with a gold seal and ribbon if they took part.
2. Surprise reward. In this condition children would receive the same reward as above but, crucially, weren't told about it until after the drawing activity was finished.
3. No reward. Children in this condition expected no reward, and didn't receive one.

While reading this study, we have to ask ourselves: Is a "certificate with a gold seal" really a reward?  Is that what best motivates children?  Do the results of this study conclude that children don't change their behaviors for rewards, or simply that the reward itself was lame?

Despite what the authors state, small rewards CAN be a powerful impetus for behavior change.  Reward is a staple of behavioral training, and in particular, rewards that release dopamine (e.g. food, sweet beverages, etc.) strongly influence brain plasticity during a training event.  To make a blanket statement on the contrary is dangerous.  Preventable disease is a huge drain on our health care system, and it's been shown that simple behavior changes like diet and exercise can reduce the burden caused by obesity, diabetes, and heart disease.  Just because a child responds in a certain way to a reward of a certificate with a gold star, I don't think we should abandon the proverbial "carrot" when trying to get people healthy.

Join My Photostream, Doc

The most impressive tool for clinical decision-making presented at the Health 2.0 conference was a program that allowed docs to share medical images over the Internet, developed by MyPACS.net.  Any DICOM image (e.g. CT scan, MRI, etc) can be uploaded and shared through their website. Say, for example, that a patient comes to the hospital with abdominal pains.  After undergoing a CT scan, the radiologist determines that there is a mass located in the abdominal cavity, but is not quite sure what it is.  Traditionally, the radiologist would either compare the patient’s CT to scans in the hospital archive, or spend hours searching through the limited information in medical journals.  With MyPACS.net, doctors can upload and share hundreds or thousands of images, instantaneously.  It’s like Facebook photos or Flickr for physicians.

Not only would this system help a small-town hospital that has limited DICOM image archives, but it also eliminates the 6-10 month lag in publication of images in medical journals.

Health 2.0 Conference Day 2: Consumer Aggregators

Welcome to Day 2 of the Health 2.0 conference.  There was an interesting talk this morning focused on "Consumer Aggregators", which demoed new applications from WebMD, Google Health, and Microsoft Heath Vault.

Wayne Gattinella of WebMD summarized the state of affairs, saying that people want to access information on the go, and there's a drastic need for medical applications to go mobile.  According to Gatinella, this means creating applications for both physicians, in a point-of-care setting, as well as patients, who want on-demand information about their health.

All three companies agreed that people are sharing more and more personal health data online these days.  Gattinella paralleled patients sharing their medical information to using credit cards online 10 years ago.  At first, people were skeptical and scared.  After successfully trying it out a few times, fears subsided, and the convenience benefit far outweighed the perceived risk.

Each application displayed different, but equally cool, themes.  Microsoft built their application around the idea that patients should be able to customize the layout as they wanted -- place your blood pressure widget here, your LDL cholesterol level widget over there.

Google Health's application stressed the fact that less than 25% of what a doctor tells a patient during an office visit is actually remembered by that patient when they get home.  Google closes this gap in communication in the MDLiveCare application by feeding all of the doctor's notes back into the patient's Google Health record, so that the patient can recap the visit at a later time.

WebMD had a nifty iPhone application with a 'symptom tracker', which launched with of a cartoon-like drawing of a human body (i.e. the "virtual patient").  Sore ankle?  Click on the virtual patient's ankle, and you'll be presented with some common symptoms that involve the ankle, such as 'swelling', 'rash', or 'laceration'.  As the patient navigates through the menu system and answers questions, their symptoms are further refined until the system figures out what is wrong.  Ultimately, the patient is presented with a description of the possible problem, e.g. "Click here for information on ankle sprain", which takes you to the WebMD entry for sprained ankles.

I really liked how the focus of this group was "on-demand" information, and all of the applications were tailored to helping the patient gain control of their medical information.  The data is theirs to begin with, let's give them a way to harness it...

Behavior Change: A Central Topic at Health 2.0

The afternoon of Day 1 of the Health 2.0 Conference was highlighted by the session, "The Patient is In".  First up, a video that documented the experiences of a group of people that recently started using patient health tools, such as online health journals that track diet or exercise, support sites for quitting smoking, or home blood test kits.

Following the video, a few of the participants were joined onstage by technology pioneer Esther Dyson.  Some panelists said that while they exercised a bit more and ate somewhat better during the course of the experiment, soon after they returned to their old (bad) habits.  Others were completely sold on the idea of self-tracking, and one particular panelist said that his daily running and mile-logging inspired his daughter and her friend to do the same.  Likewise, his neighbor, having noticed him trotting around the neighborhood several times a week, started his own walking regiment.  In the panelist's words, "People draw energy from supportive environments".

Social contagion, the idea that behavior change can be contagious, has been gaining ground.  A few months ago, I experienced the power of social contagion for myself: as many readers know, I'm a long-time runner.  But no matter how many miles I logged per week, my wife never really understood why I was out on the road, tormenting myself for hours.  It wasn't until she bought a Nike+ sensor, and her boss challenged her to a "See Who Can Run More Miles in a Month" challenge that she became hooked on running.  Now I have to spy on her website running log to make sure I still run more miles per week (yes, I'm competitive too).

Some people are inspired to change their behaviors by logging how many calories they're consuming every day.  Others are motivated by seeing friends or family stop smoking.  And for some, it takes someone else to throw down the gauntlet, and say, "I bet I can kick your butt in a race around the track" for the change to occur.

Esther Dyson concluded the session by saying that we can also drive behavior changes by associating the things we just don't like to do with small "rewards".  Personally, she rewarded the monotony of flossing with a 5-minute reprieve from her intense exercise routine.  So on days she flossed, instead of swimming for an hour, she could quit after 55 minutes.

Social contagion and little rewards go a long way in keeping people focused and motivated, and I was glad to see these ideas brought up at today's conference.

Health 2.0 Conference: Clinician-Patient Interaction

The morning session focused on clinician-patient interactions.  Executives from Myca, VisionTree, AmericanWell, and ReachMyDoctor, presented their virtual doctors' office visit tools. All of the tools had similar features, such as online scheduling, and the choice of different types of offices visits, such as IM chat or video.  Most integrated well with personal health records, so that during an office visit, the physician had access to the patient's medication refill history, or overdue routine preventive medical tests, such as blood-work, prostate screens, or mammograms.

At the end of the panel discussion, several good questions were asked.  People wondered what incentives were in place for physicians and patients to use the system, especially if each doctor was using a different system.  Does this mean that the patient will have to log on to two different websites if their general practitioner uses HelloHealth, but their cardiologist uses AmericanWell?  The panel responded that each of these web applications was part of a larger central platform.  It may be more helpful to think of each web tool as an individual iPhone app.  iPhone apps can communicate with each other and run on a single system (phone), so it's possible for these individual web tools to play nicely together in the future.  One question I had: where are all of the patient tools that plug into this central platform?  Maybe that's tomorrow's talk...

The second session brought out some pretty tough critics of the virtual doctor's office idea.  Although these new panelists liked what they were seeing and hearing, at heart, they were still physicians that saw many challenges to using these products in their own practice.  A psychiatrist was the first to challenge, saying that good psychotherapy demands face-to-face interactions.  I've seen this type of push-back from doctors before while consulting at medical device start-up companies.  No matter how transformative or revolutionary the new technology could be, unless doctors can easily integrate the technology into their current practice, the idea may flounder.

Yesterday at the Kaiser HealthCamp Un-Conference, a cool term surfaced -- "minimally disruptive technology" -- which was used to describe an approach to reform health care technology that pushed progress, while not upsetting the status quo, so to speak.  Granted, there is a learning curve associated with any new technology, and to implement an idea such as virtual doctors' office visits will require significant infrastructure changes in the medical community.

Will only a fringe group of early adapters use this technology?  Is it realistic to think that a majority of doctors will use such a system?  Too early to tell, but it wouldn't hurt to get some of the nay-sayers involved with the design while the concept is still in its early stages.

Health 2.0 Conference: Keynote Address

The Health 2.0 conference kicked off this morning, amidst the booming call-to-action by the U.S. Chief Technology Officer, Aneesh Chopra during the Keynote Address.

Chopra assured the crowd that he was "deeply committed to the role entrepreneurs play (in the future of health care)".  Yet, he wondered whether companies were using all of the resources currently available to them, when he asked "How many companies are using Small Business Innovation Research grants (SBIR) to bring their products to market?".

According to Chopra, the U.S. government has new initiatives on the horizon, such as subsidizing 2/3 of the salaries of 40 postdocs who decide to enter industry.  That means an employer can pick up a new PhD hire at 1/3 of the cost!

Chopra concluded by addressing the current economic downturn with his "light-at-the-end-of-the-tunnel" attitude by saying "the next round of Fortune 500 companies will be born in this era".

My take: it was a good introduction to the potential promise scattered throughout the room.