Category: Health

“You Don’t Venture into the Wilderness Expecting to Find a Paved Road”

(p. 40) I, . . . , always considered the heart a pump, much the way a doctor explained it to Sandeep Jauhar during his cardiology fellowship. “In the end,” the doctor said, “cardiology is mostly a problem of plumbing.”

Jauhar quickly learned otherwise. His gripping new book, “Heart: A History,” had me nearly as enthralled with this pulsating body part as he seems to be. The tone — a physician excited about his specialty — takes a sharp turn from his first two memoirs. The first, “Intern,” was filled with uncertainty; the second, “Doctored,” with disillusionment.

. . .

We go into an operating room where a young girl is having open-heart surgery, tethered to a heart-lung machine. Then we learn that the concept for this machine began with one doctor’s brazen idea of connecting a patient to another person’s blood supply. He was inspired by the way a fetus feeds off its mother. Six of seven cases ended with a death.

Eventually, the heart-lung machine replaced the volunteers. The machine got off to a rough start too: 17 of the first 18 patients died. As one of the mid-20th-century researchers remarked, “You don’t venture into the wilderness expecting to find a paved road.”

Continue reading ““You Don’t Venture into the Wilderness Expecting to Find a Paved Road””

Complexity of Drug Discovery Requires More Than A.I.

(p. B1) Every two years, hundreds of scientists enter a global competition. Tackling a biological puzzle they call “the protein folding problem,” they try to predict the three-dimensional shape of proteins in the human body.

. . .

Mohammed AlQuraishi, a biologist who has dedicated his career to this kind of research, flew in early December to Cancun, Mexico, where academics were gathering to discuss the results of the latest contest. As he checked into his hotel, a five-star resort on the Caribbean, he was consumed by melancholy.

The contest, the Critical Assessment of Structure Prediction, was not won by academics. It was won by DeepMind, the artificial intelligence lab owned by Google’s parent company.

. . .

“It is not that machines are going to replace chemists,” said Derek Lowe, a longtime drug discovery researcher and the author of In the Pipeline, a widely read blog dedicated to drug discovery. “It’s that the chemists who use machines will replace those that don’t.”

. . .

(p. 5) Working with two other computer scientists, the DeepMind researcher Rich Evans homed in on protein folding. They found a game that simulated this scientific task. They built a system that learned to play the game on its own, and the results were promising enough for DeepMind to greenlight a full-time research project.

The protein folding problem asks a straightforward question: Can you predict the physical structure of a protein — its shape in three dimensions?

If scientists can predict a protein’s shape, they can better determine how other molecules will “bind” to it — attach to it, physically — and that is one way drugs are developed. A drug binds to particular proteins in your body and changes their behavior.

In the latest contest, DeepMind made these predictions using “neural networks,” complex mathematical systems that can learn tasks by analyzing vast amounts of data. By analyzing thousands of proteins, a neural network can learn to predict the shape of others.

. . .

Mr. Hassabis said DeepMind was committed to solving the protein folding problem. But many experts said that even if it was solved, more work was needed before doctors and patients benefited in any practical way.

“This is a first step,” said David Baker, the director of the Institute for Protein Design at the University of Washington. “There are so many other steps still to go.”

As they work to better understand the proteins in the body, for instance, scientists must also create new proteins that can serve as drug candidates. Dr. Baker now believes that creating proteins is more important to drug discovery than the “folding” methods being explored, and this task, he said, is not as well suited to DeepMind-style A.I.

DeepMind researchers focus on games and contests because they can show a clear improvement in artificial intelligence. But it is not clear how that approach translates to many tasks.

“Because of the complexity of drug discovery, we need a wide variety of tools,” Dr. Alvarez said. “There is no one-size-fits-all answer.”

For the full story, see:

Cade Metz. “Making New Medicines With a Spoonful of A.I.” The New York Times (Wednesday, Feb. 6, 2019): B1 & B5.

(Note: ellipses added.)

(Note: the online version of the story has the date Feb. 5, 2019, and has the title “Making New Drugs With a Dose of Artificial Intelligence.”)

Permissionless Surgical Innovation

(p. 15) When a patient’s heart gave out on the cardiac surgeon Denton Cooley’s operating table in 1969, he refused to let the man go gently into that good night. Instead, he dispatched an associate to find a sheep and pluck out its heart. Cooley sewed it into his patient’s chest. This was apparently the kind of thing you could do — without asking anyone’s permission — in the 1960s.

The patient died (of course) but Cooley pressed on. A year later, he tried another experimental procedure — an artificial heart developed and some would say stolen from his rival at Baylor University in Houston. He never asked the university’s permission because, well, that would have required going through a committee run by said rival. “We administered to Baylor University the biggest enema,” Cooley reportedly told a colleague after the surgery. “It will be remembered in years to come.”

And this, readers, is how the first artificial heart came to be implanted in a patient. (The man survived three days with the device, before receiving a transplant from a donor and dying the following day.) Such are the brazen feats that Mimi Swartz chronicles in her book “Ticker,” a brief history of the artificial heart. Swartz is an executive editor of Texas Monthly, and she is based in Houston, home to four medical schools and much of the last century’s pioneering heart research. These are physicians who have a lot more in common, she writes, “with the people who crossed Everest’s Khumbu Icefall or took the first steps on the moon.”

For the full review, see:

Sarah Zhang. “The Tin Man’s Dilemma.” The New York Times Book Review (Sunday, Sept. 22, 2018): 15.

(Note: the online version of the review has the date Sept. 17, 2018, and has the title “The Quest to Create and Perfect an Artificial Heart.”)

The book under review, is:

Swartz, Mimi. Ticker: The Quest to Create an Artificial Heart. New York: Crown, 2018.

Absence of For-Profit Hospitals Hurts New York State

(p. A17) House Democrats’ new Medicare for All bill asserts “a moral imperative . . . to eliminate profit from the provision of health care.”
. . .
The Empire State’s hospital industry has been 100% nonprofit or government-owned for more than a decade. It’s a byproduct of longstanding, unusually restrictive ownership laws that squeeze for-profit general hospitals. The last one in the state closed its doors in 2008.
A report last year from the Albany-based Empire Center shows the unhappy results. The state health-care industry’s financial condition is chronically weak, with the second-worst operating margins and highest debt loads in the country. And there’s no evidence that expunging profit has reduced costs. New York’s per capita hospital spending is 18% higher than the national average.
The overall quality of New York’s hospitals, even factoring in Manhattan’s flagship institutions, is poor. Their average score on the federal government’s Hospital Compare report card was 2.18 stars out of five–last out of 50 states. Their collective safety grades from the Leapfrog Group and Consumer Reports magazine have also been dismal.
The state’s nonprofit hospitals also fall short on accessibility for the uninsured. On average they devoted 1.9% of revenues to charity care in 2015, a third less than privately owned hospitals nationwide.
Finally, New York’s antiprofit policy doesn’t even prevent people from getting rich. Seven-figure salaries are common among the state’s hospital executives. If banning profit is an effective way to improve health-care, there’s no evidence to be found in New York.

For the full commentary, see:
.Bill Hammond. “Banishing Profit Is Bad for Your Health; The Medicare for All proposal from House Democrats follows New York state’s bad example.” The Wall Street Journal (Tuesday, March 19, 2019): A17.
(Note: ellipsis internal to first paragraph, in original; ellipsis between paragraphs, added.)
(Note: the online version of the commentary has the date March 18, 2019.)

92-Year-Old American Airline Mechanic

(p. A19) Azriel Blackman, an airline mechanic for American Airlines, is not allowed to climb ladders, drive on the airfield at Kennedy International Airport or even use any tools.
That’s understandable — Mr. Blackman turns 92 next month.
But those constraints have not stopped him from showing up to work at a job he started in an era when trans-Atlantic commercial flights were novel feats.
“He loves coming to work,” said Robert Needham, Mr. Blackman’s boss and the station manager for the airline’s New York maintenance base. “His work ethic is something I’d love every one of my 368 mechanics here to have.”
Five days a week, Mr. Blackman drives himself from his home in Queens Village to the airport long before sunup and well before his 5 a.m. start time. His job as crew chief is to review paperwork detailing what maintenance has been completed and what remains to be done on 17 jetliners that are kept overnight at the airport. Then, wearing a lime-green vest and clutching a paper containing a list of planes and service requests, he starts his walk through a massive hangar, often passing below an enormous mural on the wall featuring his portrait surrounded by four types of aircraft flown by American.
. . .
“Every day the job is different,” Mr. Blackman said. “You’re not doing the same thing repetitively, and that’s good. If in my journey around the hangar I see something I can help on, I do that.”

For the full story, see:
Christine Negroni. “For 75 Years, Helping to Keep Planes Aloft.” The New York Times (Tuesday, June 18, 2017): A19.
(Note: ellipsis added.)
(Note: the online version of the story has the date June 17, 2017, and has the title “For 75 Years, a Mechanic Has Helped Keep Planes Aloft.” The online version identifies the page number of the New York edition as A18. The page number in my copy of the National edition was A19.)

Medtronic Founded in Garage

(p. A1) In the mid-1950s, heart pacemakers were bulky devices that had to be wheeled around on carts and plugged into a wall socket. A heart surgeon in Minneapolis asked Earl Bakken if he could make something better. After consulting a back issue of Popular Electronics, Mr. Bakken within a few weeks fashioned a wearable pacemaker powered by a battery.
. . .
Mr. Bakken, who died Oct. 21 [2018] at the age of 94, had no inkling he was creating anything more than a local repair shop when he and a brother-in-law, Palmer Hermundslie, set up Medtronic. “We didn’t analyze or study the market,” he wrote in “One Man’s Full Life,” a 1999 memoir. “We just did it.”
Medtronic’s inventions eventually sustained him physically as well as financially. “I’m on my second pacemaker, and I’m on about my third or fourth insulin pump,” he told the St. Paul Pioneer Press in 2010. “So I’m glad I invented the company, or I wouldn’t be sitting here.”
. . .
Noting his talents, university medical personnel sometimes asked Mr. Bakken to fix their equipment. He noticed that few hospitals had technical staffs to maintain their electrical gear. A chat with his brother-in-law, Mr. Hermundslie, prompted them to fill that niche by setting up a repair shop inside a garage.
. . .
In 1957, a power outage was blamed for the death of a baby dependent on a plug-in pacemaker. A University of Minnesota heart surgeon, Dr. C. Walton Lillehei, asked for alternative technology. Mr. Bakken found a design for an electronic metronome in Popular Electronics and used that as the model for a circuit. He housed the circuitry in a metal box small enough to be taped to a patient’s chest. After a successful test on a dog, Dr. Lillehei began using the device. Articles he wrote about it created a stir, and soon Medtronic was receiving orders from around the world.

For the full obituary, see:
James R. Hagerty. “Founder Started Medtronic as a Local Repair Shop.” The Wall Street Journal (Tuesday, Oct. 27, 2018): A6.
(Note: ellipses, and bracketed date, added.)
(Note: the online version of the obituary has the date Oct. 26, 2018, and has the title “Medtronic Founder Earl Bakken Turned a Tiny Repair Shop Into a Giant of Medical Technology.”)

The autobiography mentioned above, is:
Bakken, Earl E. One Man’s Full Life. Fridley, MN: Medtronic, Inc., 1999.

Bureaucratic FDA Delays Approvals for Fear “We’ll Be Toast”

(p. A21) Oct. 30 [2018] marks the 36th anniversary of the FDA’s approval of human insulin synthesized in genetically engineered bacteria, the first product made with “gene splicing” techniques. As the head of the FDA’s evaluation team, I had a front-row seat.
. . .
My team and I were ready to recommend approval after four months’ review. But when I took the packet to my supervisor, he said, “Four months? No way! If anything goes wrong with this product down the road, people will say we rushed it, and we’ll be toast.” That’s the bureaucratic mind-set. I don’t know how long he would have delayed it, but when he went on vacation a month later, I took the packet to his boss, the division director, who signed off.
That anecdote is an example of Milton Friedman’s observation that to understand the motivation of an individual or organization, you need to “follow the self-interest.” A large part of regulators’ self-interest lies in staying out of trouble. One way to do that, my supervisor understood, is not to approve in record time products that might experience unanticipated problems.

For the full commentary, see:
Miller, Henry I. “Follow the FDA’s Self-Interest; While approving a new form of insulin, I saw how regulators protect themselves.” The Wall Street Journal (Monday, Oct. 29, 2018: A21.
(Note: ellipsis, and bracketed year, added.)
(Note: the online version of the commentary has the date Oct. 28, 2018.)

P&G Bureaucracy Suffocates New Chapter

(p. A5) Vermonters Paul and Barbi Schulick sold their vitamin business to Procter & Gamble Co. in 2012, hoping P&G ‘s PG’s deep pockets would fund research needed to nurture the small-but-profitable company.
Instead of growing, New Chapter, founded in 1982 by the Schulicks, spiraled downward.
. . .
The Schulicks kept roles at the company training managers and running research and development at its offices in Brattleboro, Vt., but this month they quit. They said excessive bureaucracy hurt New Chapter and that P&G–coming off a fight with activist investor Nelson Peltz–ramped up pressure for profitability and vetoed plans to develop breakthrough products.
M”The patience factor has really worn out” at P&G, Mr. Schulick said in an interview. “There is a lot of pressure to meet targets, and we weren’t responding fast enough.”

For the full story, see:
Sharon Terlep. “At P&G, Vitamins Maker Loses Energy.” The Wall Street Journal (Friday, July 20, 2018: A5.
(Note: ellipsis added.)
(Note: the online version of the story has the date July 19, 2018, and has the title “They Sold Their Startup to P&G. It Struggled. They Quit.”)

Early Medical “Leaps of Ingenuity”

(p. A17) Using a panoply of colorful examples, the author artfully illustrates the frustrations, uncertainty, poorly founded confidence and frequent futility of medical practice in the prescientific age. Employing a consistently light and humorous touch, he effortlessly navigates a cornucopia of fascinating, esoteric and obscure patient histories.
The carefully selected vignettes demonstrate the befuddled mindset of the well-intentioned physicians who were forced to contend with the vagaries of damaged and failing human flesh without the benefit of anesthesia, and armed with little more than the fanciful theories of Galen (a second-century Greek who attributed disease to imbalances of the four “humors”: blood, phlegm, and yellow and black bile) and an elementary knowledge of human anatomy.
Yet despite their lack of mechanistic understanding, these individuals showed leaps of ingenuity no less startling than those of today’s physicians and genome rewriters. To avoid subjecting himself to the dangers of 18th-century surgery to remove a bladder stone, Mr. Morris tells us, the French-born surgeon Claude Martin fashioned an instrument out of a knitting needle and a whalebone handle, which he then inserted through his urethra and used to manually file away the stone.

For the full review, see:
Adrian Woolfson. “BOOKSHELF; Desperate Remedies; Treatments of old for common health ills included tobacco-smoke enemas, arsenic cigarettes–and the “Pigeon’s-Rump Cure.” The Wall Street Journal (Tuesday, Dec. 13, 2018): A17.
(Note: ellipses added.)
(Note: the online version of the review has the date Dec. 12, 2018, and has the title “BOOKSHELF; ‘The Mystery of the Exploding Teeth’ Review: Desperate Remedies; Treatments of old for common health ills included tobacco-smoke enemas, arsenic cigarettes–and the “Pigeon’s-Rump Cure.”)

The book under review, is:
Morris, Thomas. The Mystery of the Exploding Teeth: And Other Curiosities from the History of Medicine. New York: Dutton, 2018.

Kansas City Government Pours Bleach on Food for the Homeless

(p. A17) KANSAS CITY, Mo. — They unfurled colorful blankets on a grassy slope, and unloaded steaming trays of corn dogs, baked beans and vegetable beef soup. Every week for the past three years, the volunteers have gone to a park just outside downtown Kansas City with home-cooked meals for the homeless. They call it a picnic with friends.
But on a cloudy afternoon earlier this month, an inspector from the Kansas City Health Department showed up and called it something else: an illegal food establishment.
She ordered most of the food put into black garbage bags, bundled them on the grass and, in a move that stunned the gathered group, doused the pile with bleach.
Allen Andrews, who has been living on the streets for the past year, said he watched silently as the bleach was poured, thinking back to when he had a home. He remembered how he had sometimes poured bleach on trash he put out for collection, to deter rodents from getting into it.
“They treat us like animals,” Mr. Andrews, 46, said.

For the full story, see:
John Eligon. “‘Where Feeding the Needy Requires Both a Heart and a Permit.” The New York Times (Thursday, Nov. 22, 2018): A17.
(Note: the online version of the story has the date Nov. 21, 2018, and has the title “You Want to Feed the Hungry? Lovely. Let’s See Your Permit.” The online version says that the article appeared on p. A13 of the New York edition. It appeared on p. A17 of the National edition that I subscribe to.)

“Profit Feeds Impact at Scale”

(p. 1) Eric Reynolds will tell you that he is on the verge of freeing much of humanity from the deadly scourge of the cooking fire. He can halt the toxic smoke wafting through African homes, protect what is left of the continent’s forest cover and help rescue the planet from the wrath of climate change.
He is happy to explain, at considerable length, how he will systematically achieve all this while constructing a business that can amass billions in profit from an unlikely group of customers: the poorest people on earth.
He will confess that some people doubt his hold on reality.
“A lot of people think it’s too good to be true,” says Mr. Reynolds, a California-born entrepreneur living in Rwanda. “Most people think I am pretty out there.”
The company he is building across Rwanda, Inyenyeri, aims to replace Africa’s overwhelming dependence on charcoal and firewood with clean-burning stoves powered by wood pellets. The business has just a tad more than 5,000 customers and needs perhaps 100,000 to break even. Even its chief operating officer, Claude Mansell, a veteran of the global consulting company Capgemini, wonders how the story will end.
“Do we know that it’s going to work?” he asks. “I don’t know. It’s never been done before.”
Inyenyeri presents a real-world test of an idea gaining traction among those focused on economic development — that profit-making businesses may be best positioned to deliver critically needed services to the world’s poorest communities.
Governments in impoverished countries lack the finance to attack threats to public health, and many are riddled with corruption (though, by reputation, not Rwanda’s). Philanthropists and international aid organizations play key roles in areas such as immunizing children. But turning plans for basic services into mass-market realities may require the potent incentives of capitalism. It is a notion that has provoked the creation of many businesses, most of them failures.
“Profit feeds impact at scale,” says Mr. Reynolds, now in the midst of a global tour (p. 8) as he courts investment on top of the roughly $12 million he has already raised. “Unless somebody gets rich, it can’t grow.”
More than four decades have passed since Mr. Reynolds embarked on what he portrays as an accidental life as an entrepreneur, an outgrowth of his fascination with mountaineering. He dropped out of college to start Marmot, the outdoor gear company named for the burrowing rodent. There, he profited by protecting Volvo-driving, chardonnay-sipping weekend warriors against the menacing elements of Aspen. Now, he is trying to build a business centered on customers for whom turning on a light switch is a radical act of upward mobility.
. . .
To succeed, a stove had to be so convenient and clean burning that women preferred it over their existing cooking method.
Mr. Reynolds began testing stoves made in Italy, India, the United States and China. He tried making his own.
He came to realize that the magic was in the combination of stove and fuel. He experimented with making charcoal out of corncobs. (“A stupid idea,” he says.) He tried burning banana leaves. Then he discovered wood pellets, which involve compressing wood and eliminating water, the element that produces much of the smoke.
He settled on a Dutch-made stove that reduces wood down to clean-burning gases. Using pellets reduced the need for wood by 90 percent compared with charcoal. But those stoves cost more than $75.
Then came the epiphany: Inyenyeri could supply the stoves for free while collecting revenue from subscriptions for pellets. Rwanda was urbanizing rapidly, and city dwellers rely on charcoal. They would be eager to switch to pellets, which were 30 to 50 percent cheaper.
. . .
(p. 9) The business model would get more attractive as the cost of charcoal climbed, and as innovation inevitably made stoves more efficient. Inyenyeri would also stand to collect revenue from an arrangement it later entered into with the World Bank to sell credits for reducing emissions.
In 2010, Mr. Reynolds sold his house in Boulder and went all in on Inyenyeri. He unloaded his wine cellar, liquidated his retirement accounts and moved to Rwanda with no plan to leave.
. . .
“This business model will happen,” he says. “If it’s not Inyenyeri that’s the first mover, then it will be someone else who learns from our mistakes and does it better. It’s too big of an opportunity.”

For the full story, see:
Peter S. Goodman. “‘A Low-Cost Fix for Africa’s Silent Killer.” The New York Times, SundayBusiness Section (Sunday, Dec. 6, 2018): 1 & 8-9.
(Note: ellipses added.)
(Note: the online version of the story has the date Dec. 5, 2018, and has the title “Toxic Smoke Is Africa’s Quiet Killer. An Entrepreneur Says His Fix Can Make a Fortune.”)