(just an edgy subtitle, it’s not complicated, don’t worry)

It’s a dreary afternoon when a telegraph operator in Bletchley Park sends out the following signal:

— — . — — —

An office in King’s Cross receives it. A rather plump man wearing a black suit and smoking a pipe begrudgingly taps out the same signal:

— — . — — —

An operator in a somewhat grander building in Whitechapel receives the message and send’s her own:

… — — — — . — — .

Finally, this is received by Battersea power station, which reduces the supply of coal going into its furnace and the amount of energy produced.

(If you don’t know morse code the first two messages spell out ‘go’ and the last ‘stop’.)

Believe it or not our brains operate in a very similar fashion to the telegram operators that we met in just a moment ago. After all, our brains are essentially a network of interconnected neurons (the offices) that send out electrical impulses (the morse code). Indeed the signals transmitted in the brains are even simpler morse code, either there is a signal or there isn’t. A 0 or a 1. To complicate matters slightly some neurons are excitatory, whilst other’s are inhibitors.

Let’s first look at the excitatory neuron. When it receives a signal, it will emit excitatory chemicals to activate a nearby neuron. This is like the operator at Bletchley sending a ‘go’ signal to King’s Cross. However, there are also inhibitory neurons. These may recieve an excitatory ‘go’ input but they will release inhibitory ‘stop’ chemicals to nearby neurons. This is like the operator at Whitechapel sending a ‘stop’ morse code even though she received a ‘go’. One final thing to mention is that neurons integrate signals. So in reality the operator at Whitechapel would likely recieve signals from several areas (perhaps Fulham, Highgate, Islington, Camden and Mayfair), then only if there are enough stimulatory signals converge on Whitechapel will the operator send a ‘stop’ signal to the power station. So although the impulse of a neuron is all-or-nothing, the activation of a neuron leading to an impulse is graded.

Ok, where am I going with this you might wonder? …

Well understanding the above paragraph is pretty much all you need to understand the neural mechanisms behind sleep and pretty much an other neural pathway. So let’s just dive right into a bit or neuroscience and specifically the brain circuits that put us to sleep. Because, if we understand these, we will understand how to manipulate them. This will help improve the quality of our sleep and ultimately live happier, healthier, lives.

The Brain Circuits of Sleep

The primary inhibitory chemical in the brain, and the one most closely associated with sleep, is called GABA (gamma-amino-butyric acid). This is why many sedative drugs such as benzodiazepines target GABA receptors. But that’s a story for another time. The neurons that release this chemical, in the context of sleep, are found in the ventrolateral (bottom) and median (central) pre-optic areas (basically the centre of the brain). This is one of the oldest parts of the brain and often regulates unconscious activities. This suggests that sleep evolved a long time ago and also that we can’t consciously decided to fall asleep at any given moment, which I feel is a lost opportunity on the part of evolution.

In any case, the neurons in this area are most active in non-REM sleep (when you just go to bed) and least active during wakefulness. The exact pathway of the these neurons rests on a ‘switch’. This is the ‘wake-sleep’ switch, which receives inhibitory inputs from the pro-optic area and excitatory inputs from elsewhere. It is the balance between these inputs that determines the state of the brain: awake, asleep or somewhere in between. Consequently, this ‘switch’ is very much like Whitechapel in our story. A central hub, where impulses converge the balancing of which, either switches off or switches on the ‘Battersea power station’ of the brain.

Indeed, once the inhibitory signals converging on the ventrolateral preoptic area fall below a certain threshold then a wave of inhibitory impulses are sent out inhibiting the ventrolateral periaqueductal grey, the pontine tegmentum, the monoamine system, which sound like cult names but are actually regions of the brain associated with wakefulness.

Ok, we’re done with the jargon, you can take a breath now.

In essence, there is a switch in the brain which is suppressed by the excitatory regions of the brain. When these excitations begin to diminish (when we’re tires) this switch is flipped and a huge burst of GABA floods the brain inhibiting activity, which leads to sleep.

Why Do We Sleep?

This is a question that people have asked for … well as long as there have been people and although we may not know everything yet, we do have a few good ideas. One of the current hypotheses is called homeostatic plasticity. The idea is that as we use our brains a build up of toxic chemical occurs known as somnogens. These are a direct by product of neuronal processing i.e thinking. When we sleep these somnogens are cleared away restoring our ability to process the vital information of a cat meme on the following day. From this perspective, sleep is the price we pay for having a brain, which on balance seems like quite a good deal. Perhaps evolution didn’t mess up after all. Consequently, sleep is vital to our health and a new trend is emerging, which sees sleep as a preventative measure to stave off neurological decline. As we have already seen in a previous publication, matcha may be another way so be sure to check out that article.

“Toward this end, an emphasis on looking at sleep health as a preventive measure in the effort to stave off neurologic decline is growing in evidence-based support and clinical awareness.”

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So now we know how sleep works, we know what it’s for and why it’s important so what can we do about it?

Modulating our Sleep

(aka: The rise of the floofy blankets)

A meta-analysis (analysis of an analysis and yes the paper is as dry as it sounds) published in 2021, investigated the potential benefits of several supplements on sleep quality. The reason why a meta-analysis is so useful is that the exact same study conducted twice can give different results due to the nature of probability. Doing a meta-analysis helps us to be more sure (although not completely) in our conclusions. If you want to read more on this take a look at ‘beware the man of one study’. Another thing to be aware of is that the meta-analysis can only express a relative improvement. This is because different studies look at different parameters (e.g duration, quality, or sleep latency). Consequently, this study decided to look at the difference in the means as a measure of improvement. In this article I will state the values for you to be able to compare the supplements but just be aware that this is not an absolute measure of efficacy.

Keeping the statistical limitations in mind, the paper found some interesting results.

The supplement that brought about the greatest benefit according to the analysis was Vitamin-D. The data for this is based on five studies conducted between 2017, and 2018. The study reports a mean difference -1.63 with a 95% confidence interval of (-3.15, -0.10). This means that the true value has a 95% chance of being inside that range.

The analysis also looked across seven trials of melatonin supplements and found a mean difference of -1.21 with a CI (95% confidence interval) of (-2.17, -0.24).

The last supplement to have a significant impact was amino acid supplements with a mean difference of -1.27 and a CI of (-2.35, -0.20)

Conclusions

Does this mean we should all feverishly run to the nearest store and intravenously administer vitamin-D directly into our veins as if the end of times is upon us? Probably not. Indeed, some of us are lucky enough to be able to get a solid 8 hours of sleep each night, for whom it is unlikely that supplements are necessary. However, there are those who struggle to sleep adequately, either they work night shifts, look after children, or have a sleeping condition. For those, it may be worthwhile to think about ways of improving their sleep. This may include a supplement, alternatively it may include improving the environment in which they sleep (e.g the correct temperature and light levels), which unfortunately we will not have chance to explore in this article. However, even in those cases always make sure to follow the respective guidelines on the packaging and, as always, the advice of your health professional.

Yegor Lisle (he/him) is a UCL MSci Pharmacology student. He is curious about the nature of biology, the origin of life, and the biochemistry of the universe. In particular he wants to understand more about the interface between biology, chemistry and physics.

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like to stay in touch and join the conversation, subscribe below!

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Previously in this publication, we have explored adjacent topics such as Honeybee Healthcare which looked at the importance of locally contextualized care, and The Cuban Paradox which explored the Cuban healthcare system's outsized patient outcomes. In both articles, we have touched on the importance of community-centred care, but we have yet to address how such care might be structured.

As I've already hinted, Happily Ever After believes in the network approach to healthcare- this article explains why.

The fundamentals of networking

To start, it is worth defining what constitutes a network. A network is a system architecture that consists of similar nodes, which are connected together to allow for coordination and communication. Importantly, a network is a flat organizational structure, and it is built of peers which each peer holding roughly equal powers and rights as any other peer.

The opposite of the flat network is a tree structure that we are all familiar with - hierarchy. Hierarchies are ordered levels, where each level has more power than the level below. Hierarchies cascade control from the highest level to the lowest, for all tasks that the system must perform. In contrast, networks operate as a heterarchy, which can be unranked (every node has equal power) or ranked in multiple ways depending on the task.

For example, imagine a system with 3 nodes. In a hierarchical model, regardless of the decision that needs to be made, the node with the highest level is the node that has the ultimate deciding authority. But in a network, all three nodes could have the same decision authority in which case the decision is settled by a vote, or there could be a decision-dependent hierarchy that was agreed upon within the network.

Most modern organizations share elements of both heterarchy and hierarchy, although, at the system level, the hierarchy level picture dominates. This is evident from things like organization charts, and widely respected positions of power like the Chief Executive Officer.

One of the pioneering works in this classification comes from the early internet pioneer, David Ronfeldt from the RAND Corporation. In his paper Tribes, Institutions, Markets, Networks (TIMN), David lays out the narrative of social coordination as progressing through distinct organizational forms.

In his view, each form is a more evolved version of its prior, and he presents a whig account of humanity's increasing coordination potential.

Good Organizations, Bad Organizations

But to properly understand the utility of networks, it is important that we consider what makes an organization good. Why do we even organize?

The limiting factor of human coordination is trust, through the form of various prisoner's dilemmas. This lack of trust manifests as a transaction cost, which is the perceived friction of collaborating with an external person or entity. Good organizations lower transaction costs, by attempting to align incentives, create repeated games to overcome the prisoner's dilemma and lower other techno-social barriers to collaboration.

To give a concrete example, imagine that you are a carpenter looking to build a bed. However, for a specific order, you require the assistance of a wood sculptor for the aesthetic finish. Normally, that would require negotiation between the two parties as to the rewards and expectations of the work. That is the transaction cost incurred.

Instead, if the wood sculptor and carpenter were working at the same company, then they can simply collaborate without worrying about the negotiation, which is conducted automatically by a previously established protocol. Here, a hierarchical institution enforces protocols to reduce transaction costs and improve collaborative output.

So for a given situation, an organizational system is better when it reduces transaction costs more than any other alternative.

Networks are anti-wicked

Looking back to the context of healthcare, our previous articles have gone into detail explaining the interdependence of our health with our social contexts and other goods. This "messiness" is what social scientists call a wicked problem.

The search for scientific bases for confronting problems of social policy is bound to fail because of the nature of these problems... Policy problems cannot be definitively described. Moreover, in a pluralistic society there is nothing like the indisputable public good; there is no objective definition of equity; policies that respond to social problems cannot be meaningfully correct or false; and it makes no sense to talk about "optimal solutions" to these problems... Even worse, there are no solutions in the sense of definitive answers.

- Rittel and Webber

In a way, wicked problems cannot be characterized as problems in the scientific-engineering sense. Instead, they are problem-generators, an infinite game which can be played forever, where every applied solution introduces more problems to be solved. This gives ecosystems with wicked problems, a certain quality of aliveness, with the ability to respond and evade applied solutions akin to a bacteria evolving antibiotic resistance.

The solution to a problem generator is a solution generator. A wicked problem can be resolved with an autopoietic system, capable of continually evolving and addressing new problems.

The first is to shift the goal of action on significant problems from "solution" to "intervention." Instead of seeking the answer that totally eliminates a problem, one should recognize that actions occur in an ongoing process, and further actions will always be needed.

- Wholesome Design for Wicked Problems

In Honeybee Healthcare, I wrote about the locality-dependence of healthcare which makes everything even more complicated. In healthcare, every local context is an independently wicked problem. A solution that works in one place, could have the opposite effect in a place with a slightly different context.

And this problem is where hierarchies fail. Hierarchies being tree structures, concentrate decision-making power at the top. But the inherent complexity of just one wicked problem, let alone N independent wicked problems is far too much for any person or small group to handle. In contrast, networks act as a swarm of independent units, which are autonomously privileged to come up with solutions that are customized for their local wicked problem.

The practice of rational command and control in hierarchies (OKRs, 10-year-plans, performance reviews) also falls short in the face of complex systems. Instead in Reinventing Organizations, Frederic Laloux calls on network organizations to

"Sense and respond" instead of "predict and control”

By making peace with the reality of wicked problems, networked organizations aim for good-enough solutions that can be iterated quickly - making them natural solution generators. All of this is hard to grasp, how do we measure what works without organization-wide metrics, objectives and goals? And yet it is unsurprising that messy hard-to-quantify problems require messy hard-to-quantify solutions, recalling Ashby's Law of Requisite Variety.

In order to be efficaciously adaptive, the internal complexity of a system must match the external complexity it confronts.

Networks in the Wild

But this is not to say that, these systems are entirely non-quantifiable. And before dismissing them as one of those idealistic ideas which are practically impossible, it is worth noting that networked organizations are neither new nor impossible.

In 2011, Ewan Ferlie et. al published Public Policy Networks and 'Wicked Problems' which reported a shift from hierarchical public service organizations to network forms using evidence from UK-based organizations such as the NHS. The paper specifically highlights the relevance of network forms to wicked problems, citing examples such as the behaviour change in older adults achieved by the Older People's Network. Even the partial use of heterarchical organization allowed these institutions to cut through multiple jurisdictions and operate in "small, scattered and autonomous" groups.

Additionally, Charles E. Lindblom's paper The Science of Muddling Through advocates for the iterative style of approaching wicked problems, even in the absence of clear overarching objectives and plans. Instead in his view, the rational comprehensive method which attempts to centralize, predict and control the outcomes of a policy is in fact the actual practical impossibility.

Policy is not made once and for all; it is made and re-made endlessly.

An example we admire in Happily Ever After is Buurtzorg Nederland, which was established in 2006 with a network-based model of home-based nursing care. Buurtzorg's network consists of small independent squads of nurses working to serve a particular neighbourhood's care needs. It consistently reports some of the highest client and workplace satisfaction rates of any healthcare organization and has recently expanded its model of care to the UK.

Cautions for the Network Builder

The network approach is not without its challenges. When Buurtzorg ran the Transforming Integrated Care in the Community (TICC) initiative to replicate heterarchical principles into existing institutions, it found resistance working against contexts where network-thinking values, cultures and goals were not shared.

In Formal Structures are Myth and Ceremony, John Meyers writes about the organizational imperative to comply with existing norms of operation. He asserts that organizational survival goes beyond achieving efficiency in the desired purpose, crucially because of the need to maintain relationships with institutional environments for legitimacy.

Organizations that incorporate societally legitimated rationalized elements in their formal structures maximize their legitimacy and increase their resources and survival capabilities.

This is especially important to organizations that depend on the ceremonial demands of external institutions. Unfortunately, healthcare is one of those institutions with rules which impose costs on iconoclastic but potentially more efficient organization structures. This makes Buurtzorg's local success even more surprising, as these factors appear to play a much larger role in projects like the TICC.

Additionally, the legal and technological infrastructure to support these organizational forms is nascent. Adjacent experiments such as Decentralized Autonomous Organizations offer some hope on this front by providing early prototype tools to run networked organizations.

Networks Work

Healthcare, education, transportation and beyond hold many wicked problems waiting to be solved, and heterarchies seem well poised to revolutionize organizations in civil society. The autonomous social sector has long been torn between government bureaucracy (NGOs) and market pressures (social enterprises), and networks offer a third modality that could be values-aligned to deliver public goods and services.

Yet, there remains lots of work to do, to see if networks will play a big role in solving these problems. From building new organizational tools to writing policy papers to increase the legitimacy of networked organizations, there are many hurdles for the builders of networks to cross.

For our part, Happily Ever After, continues to believe that networks are the optimal way to achieve our purpose of universally accessible preventive care. We are leading the charge in building tools and protocols to help other networks follow our lead. If you believe that networks work too, get in touch and join us on our mission :)

Sudharshan Sundaramahalingam (he/him) is a core steward of Happily Ever After, where he is building a future for healthcare that is community-centred and focuses on collective flourishing. He spends his spare time brewing coffee, being an amateur philosopher and dealing with his 20s through writing. | Twitter | Website

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like to stay in touch and join the conversation, subscribe below!

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The health benefits of catechins, the active ingredient in tea are broad and have been implicated in diseases such as cancer, neurodegenerative diseases and even COVID-19. However, in today’s Tea Time we’re going to look more closely at the impacts of tea in cardiovascular disease.

What is a Cardiovascular disease?

Cardiovascular disease is really an umbrella term that includes several medical conditions that effect the heart. For example, coronary heart disease (CHD), congenital heart disease, and peripheral arterial disease are all types of cardiovascular disease.

This condition is the leading cause of death worldwide especially in highly developed countries, which tend to have older populations with higher rates of obesity. Now that we known a little bit about the context, we’re going to have a closer look at three types if of cardiovascular disease, namely CHD, Heart Failure (HF).

A diagram of the heart including the names of the major arteries, veins, and chambers.

Coronary Heart Disease

Firstly, let’s talk about what CHD actually is, according to the NHS.

Coronary heart disease is the term that describes what happens when your heart's blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries.

This constricting of the arteries leads to reduced oxygen supply to the heart and results in symptoms of angina (heart pain), shortness of breath and nausea.

Published in 2018, one clinical trial tried to establish a link between tea catechin and the risk of stroke and CHD. The study included men and women, aged 40-69, that had no previous history of heart disease, stroke or cancer. Unfortunately, no significant direct link was established between catechin intake and the likelihood of stroke or CHD. However, it was observed that non-smoking men that had high catechin blood levels did have a reduced risk of stroke. This lead to the researchers proposing that catechins provide a protective effect against stroke.

Heart Failure

Heart failure is a serious medical condition that results in the inability of the heart to pump blood to the tissues of the body, which can be fatal. The disease is also defined by the NHS as:

Heart failure means that the heart is unable to pump blood around the body properly. It usually happens because the heart has become too weak or stiff.

It has been established that a particular catechin known as EGCG, which we met in the previous publication of Tea Time, is the active ingredient in tea. Investigators used a technique known as echocardiography, which is just a technical way of saying using sound to measure the heart. Using this measurement method, they showed that EGCG reversed myocardial fibrosis, oxidative stress and cardiomyocyte apoptosis, which are all causes damage to the heart and are up-regulated during heart failure. For those that may be unfamiliar, myocardial fibrosis is a pathological condition that means a scarring of the heart tissue, which leads to heart failure. Oxidative stress is essentially damage caused to tissues by toxic chemicals known as reactive oxygen species (ROS). In healthy individuals the body has mechanisms of moping up these ROS. However, in older patients and smokers ROS increases and can contribute to HF. Finally, cardiomyocyte apoptosis is just the medical jargon for heart cell death, which needless to say is not good. Importantly, the chemicals in tea help to combat these physiological pathologies.

As we’ve just seen it seems that catechins could have a really beneficial impact on heart health. We’ve even seen that in the case of heart failure, and to a lesser extend CHD, green EGCG can act as a kind of preventative medicine.

So why isn’t the NHS giving us prescription Matcha paid for by the HM Treasury?

Well, there are a few reasons. Firstly, many of the studies that we’ve looked at have been conducted in animal models instead of humans so it’s not entirely clear if the effects will translate. Also, many of these studies use isolated EGCG instead of tea. This means that the dose that is being given to these animals is not necessarily comparable to the dose you might find in your average matcha latte. This is why we need more research in humans to see if these food products can have genuinely beneficial impacts on our health.

Nonetheless, I hope that the next time you make yourself that delicious green beverage you’ll remember all of the amazing molecules it contains and the fantastic science that it has allowed us to discover.

On a final note, this is one in a series of articles looking at the health benefits of tea. So, make sure to read our previous articles and look out for more in future publications of ‘The Pink Zone’.

Previous Article:

Yegor Lisle (he/him) is a UCL MSci Pharmacology student. He is curious about the nature of biology, the origin of life, and the biochemistry of the universe. In particular he wants to understand more about the interface between biology, chemistry and physics.

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like to stay in touch and join the conversation, subscribe below!

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Incremental Cost-Effectiveness Ratio (ICER)

A tool used by governments to make a decision on healthcare interventions is the incremental cost-effectiveness ratio (ICER). ICER is calculated by dividing the incremental cost of the intervention by the incremental benefit it provides. The incremental cost is relatively easy to calculate, as it is the difference in the cost of the new intervention and the standard intervention. It also includes the differences in the costs of potential follow-up treatments that may be required in the future, depending on the timescale being studied.

The benefit of a healthcare intervention is often expressed as quality-adjusted life years (QALYs). QALYs are a measure of the quality and quantity of life gained from a healthcare intervention. It takes into account not only the length of life gained but also the quality of that life. A year of life free from disability or disease would be assigned a higher value than a year of life lived with a chronic illness or disability. 1 QALY equates to one year in perfect health while 0 QALY equates to death. 0.5 QALYs may mean half a year in perfect health, one year in “half-perfect” health or any other combination. Calculating a QALY requires two inputs - The utility value associated with a given state of health and the years lived in that state. The measure of utility is derived from clinical trials and qualitative studies that measure how people feel in these specific states of health. Hence, QALYs can be subjective, albeit they are backed by clinical studies to strengthen the evidence for a QALY of a given health state.

The incremental health benefit is the gain/loss in the QALYs between the two interventions. It also takes into account the potential changes in health states in the future and the associated QALYs for them, depending on the timescale being studied. Therefore, ICER is expressed as the cost per QALY gained (i.e. $/QALY).

The Use of ICER in Healthcare Systems

ICER is used by healthcare systems to decide whether a healthcare intervention is cost-effective, or in layman's terms “worth it”. If the ICER is below a certain threshold, the intervention is considered cost-effective, making it more likely to be implemented. On the contrary, if it is above the threshold, it is considered to not be cost-effective, reducing the chances for it to be implemented.

The NHS is one of the few countries to have explicitly stated ICER thresholds. Specifically, anything below £20,000/QALY is accepted and anything above £30,000/QALY is rejected. Interventions with an ICER in between these two values would be further discussed before making a final decision. These thresholds are also one of the lowest values for a first-world country, showing the financial strain that the NHS has been in. A higher threshold would mean the healthcare system is willing to spend more money for a certain amount of benefit.

It should also be noted that compared to private healthcare systems, public healthcare systems, like the UK’s NHS, typically have much lower ICER thresholds as healthcare is free for its citizens. Hence, with a fixed budget, using the money for an intervention that is not cost-effective means that the budget is reduced for a potentially more cost-effective intervention, even if it is for a completely different health issue. Hence, fewer people would be able to benefit and potentially more people may not receive life-saving treatment. On the other hand, private healthcare systems like the US have much higher ICER thresholds as they are more driven by profits and can pass the costs onto patients and/or their insurance. That being said, private healthcare systems tend to have more than one option for a given health issue to cater to the differing budget constraints between patients.

Criticisms and Limitations of ICER

The biggest criticism of ICER is that it literally puts a price on health and life. To many, healthcare is a fundamental human right, and it should be analyzed more in-depth. Alternatively, there should not even be a budget for healthcare and everyone should be provided with the necessary treatment. Realistically, this is impossible and while ICER may not be without its flaws, its crudeness of putting a literal price on health is what also makes it a strong, decisive tool in making decisions.

Another, more valid, criticism (or limitation) of ICER is that QALYs may not always paint an accurate picture. For instance, a stroke patient today has a much higher chance of living an otherwise healthy life compared to 20 years ago. However, the difference in QALYs for a stroke patient versus a healthy person may be larger on paper than it is in reality. It is indeed hard to put a number as to how healthy a person is with a certain condition, considering the nearly infinite combinations of conditions and their severity, combined with the inherent differences between individuals. These factors may make it near impossible to get an accurate value for QALY. Regardless, there is no perfect solution to put a value on health but research has been relatively in-depth to put a value in terms of QALYs, such as numerous clinical and qualitative studies to get an as accurate QALY value for a given health state as possible. Thus, we cannot discount the importance of QALYs for ICER calculations.

Another limitation of ICER is that it can vary significantly according to the timescale that is being studied, which can vary from a few days to decades. An example is the use of immunotherapy to treat cancer. Immunotherapy can be expensive in the short-term but may provide better long-term benefits than the standard treatments (e.g. chemotherapy) in terms of increased survival rates and improved quality of life. The short-term ICER for immunotherapy may be high, but the long-term ICER may be more favourable because of the potential for long-term benefits. Therefore, the timescale chosen can be very important and it is important that healthcare systems place more emphasis on long-term ICER. Unfortunately, this is often not the case as budgets for healthcare systems are typically allocated on a yearly basis. Therefore, the decision-makers may feel that the long-term benefits may not be justifiable for the short-term increased costs, especially if the budget has to come at the expense of other treatments. That being said, healthcare systems should make a shift to focus significantly more on treatments with better long-term ICERs as this would increase the overall health of the society. It would also decrease costs in the long term as treatments with better ICERs would reduce the number of people who need follow-up treatments in the future.

All in all, ICER remains an important tool for healthcare systems to make resource allocation decisions. It provides a way to compare different healthcare interventions based on their cost and effectiveness, and it can help healthcare systems to control costs while still providing high-quality care to maximize the benefit for society.

Hi, I'm Mayank Goel, a Master of Public Health (MPH) student at Imperial College London and a Bioengineering Graduate from Nanyang Technological University. | LinkedIn

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When I first thought about this, it felt frivolous and perhaps even privileged. In most contexts, coaches are considered a luxury service, for people who can afford the hefty fees that they charge per hour. But just because something is expensive, doesn’t necessarily mean that it is a luxury. This is especially obvious in healthcare, doctors delivering medical care are not considered a luxury any more than having access to public transport is, even as doctors are considerably more expensive.

Are coaches essential?

This implies that coaches are considered a luxury service not because they’re expensive but because people don’t think of them as essential. And yet, I’d argue they increasingly are.

In our post on the social determinants of healthcare, I explored the myriad of factors that determine an individual’s health outcome. Today, coaches are one of the few professionals who are trained to acknowledge, understand and act on the imperative of holistic, human-centred care that was emphasized in that post.

This is especially relevant to Happily Ever After’s broader vision for preventive care. Coaches play a key role in the high-touch, locally relevant and team-based form of care that is considered the holy trinity of proactively delivered healthcare.

We must demand universal coaching just as much as we demand universal healthcare.

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High-touch care

Firstly, health coaches play an important role in delivering high-touch care that encourages long-term behavioural change. This personalized approach to care not only improves individual health experiences but also outcomes, and this is not a novel discovery. Since as far back as 2010, integrated care providers such as Iora Health have placed health coaches front and centre, working closely with individuals to implement lifestyle changes that are tailored to their unique circumstances.

They also go to people’s homes. They can evaluate how the patient is doing, whether their home is safe, if they have food. A lot of times the health coach goes to the grocery store with the patient. They encourage the patient to shop for everything they usually would, and then they’ll look in the cart and help the patient figure out why some of it is a bad idea and what possible substitutes are. Taking patients for walks is something else they do. It’s a really good way to talk about and model exercise behavior.

Rushika Fernandopulle, CEO, Iora Health

Through examples like this, it is obvious that health coaches spend far more time with patients than physicians ever could. And in doing so, they help individuals feel heard and provide a human touch to what is an increasingly transactional medical experience.

Locally-relevant care

Another advantage of health coaches is their ability to provide locally-relevant care that is tailored to specific communities. Unlike physicians who often rely on standard care protocols, coaches can spend more time understanding and improving the social determinants that influence health outcomes in their populations.

This approach not only improves patient outcomes but also helps to build trust and a sense of community within a care group. With the autonomy to communicate and collaboratively problem-solve alongside patients, health coaches are driving a global shift towards patient-centred healthcare.

Team-based care

In addition to the above, team-based care models also improve the division of labour, enabling doctors to focus on diagnosing and treating medical conditions while health coaches focus on helping patients execute lifestyle changes. By working collaboratively, doctors and health coaches can provide a more comprehensive approach to patient care that simultaneously addresses both medical and lifestyle factors that affect individual well-being.

Looking beyond healthcare, coaches can also be equipped to support individuals across different facets of life like jobs, finances and family, which are all interdependent in giving rise to an individual’s sense of holistic well-being.

Still, discourse on coaches is limited, even as preventive care grows in popularity. While the new field of lifestyle medicine is focused on helping doctors understand holistic preventive care, it does little to address existing physician shortages while increasing the burden of responsibility on them. This approach could inadvertently reduce access to healthcare, and distract physicians from their specialized duties of diagnosing, conducting medical procedures, and creating care plans for specific clinical contexts.

Yet many physicians remain reluctant to share responsibility for an individual’s holistic health. This is partly because they derive fulfilment from understanding and managing the full picture of an individual’s health status. Moving the responsibility of regular care away from physicians to coaches, risks eroding the physician-patient relationship and making physicians feel even more detached from the people they serve.

There is also the concern that coaches who are not trained clinically might not have the correct expertise to make decisions, and that clinicians might fall out of the loop of care plans. To me, these seem more like organizational challenges, rather than dealbreakers. Small, lean care teams could streamline communications with the right operational wisdom which should help alleviate many of these concerns. Organizations like Buurtzorg and Iora Health are role models for these kinds of teams.

Pragmatism in Healthcare

I think it’s easy to say things like “doctors should care about a patient’s whole health”, but the practical, on the ground reality makes this infeasible. We simply do not have enough doctors with enough time. If we don't figure out scalable care models, the people who will be most impacted are ones that can’t access care and likely need the most support for lifestyle modifications.

Nikhil, Out Of Pocket

As Nikhil put it, when weighing the pros and cons of the situation, pragmatism is key. To me, burdening physicians with ever more responsibility comes with a “saviour syndrome” flavour that overemphasizes the role of the individual physician in our health and well-being. In contrast, team-based approaches with an emphasis on coaches spreads responsibility and allow both physician and coach to do what they do best - leading to optimal outcomes for patients.

Coaches also are more affordable and accessible than physicians, and accessibility is critical here. For the global shift to preventive care, we need many more care professionals working to help individuals craft and adopt healthier and happier lifestyles. Having all of these care professionals be physicians, might simply not be financially viable for any healthcare ecosystem.

In any case, one thing is clear. Coaching’s public image as a luxury good must change over the coming years for the shift towards preventive healthcare to succeed. One part of this is improving costs and accessibility while integrating coaches into our health ecosystem. But a large part of it is also education, and teaching people about the importance of coaching for long-term health and well-being.

In short, to substantially move the needle away from reactive forms of healthcare, we must demand universal coaching just as much as we demand universal healthcare.

Sudharshan Sundaramahalingam (he/him) is the co-founder of Happily Ever After, where he is building a future for healthcare that is community-centred and focuses on collective flourishing. He spends his spare time brewing coffee, being an amateur philosopher and dealing with his 20s through writing. | Twitter | Website

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like to stay in touch and join the conversation, subscribe below!

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However, the traditional method of treating obesity, which involves changing lifestyle factors is difficult, time-consuming, and often ineffective. Consequently, there is a heightened demand for pharmacological interventions. This is where drugs such as semaglutide and liraglutide come in. Although they were originally developed as anti-diabetics, they have recently found a role in treating obesity. In this article we’ll discuss how exactly these medications work.

Are these medicines effective?

Several clinical trials have found that both semaglutide and liraglutide are more effective at causing weight loss than placebo, with semaglutide the superior drug of the two. The typical weight loss was around 5% for semaglutide across most clinical trials. A maximum of 15% weight reduction was reported. None of the clinical trials saw weight gain with these drugs. However, these trials were conducted with mostly caucasian participants. Consequently, more work needs to be done to understand the effects of these drugs in people of other ethnicities.

What are the general effects ?

The physiological effects, meaning the symptoms, that these drugs cause have been extensively documented and observed through several clinical trials conducted on liraglutide and semaglutide. In general, it has become clear that these drugs cause a reduction in food consumption without affecting the taste. In addition, these drugs have been shown to increase insulin secretion and reduce glucagon secretion, which is a hormone that stimulates a reduction in blood sugar levels. So it’s unsurprising why these drugs were first used to treat diabetic patients. The main question now is how exactly do these physiological effects arise? What is the mechanism behind the reduction in appetite?

Foreword on GLP-1 receptor agonists

Collectively, semaglutide and liraglutide fall under the category of GLP-1 receptor agonists. All this means is that both drugs activate the GLP receptor, which stands for glucagon-like peptide. Yep, it was first discovered because it binds to a peptide (protein) that is similar to glucagon. I know … shocking. As you can tell, pharmacologists are a bunch of super creative and imaginative people. Anyway, you may be wondering what exactly a receptor is. In essence a receptor is a protein that binds to a molecule and passes on a message to the inside of the cell, which causes the cell to do something in response. I like to imagine the cell as a medieval fortress ruled by a paranoid king that likes to keep all the gates to his castle closed so that no-one can travel inside or out. But the king still needs to know what is going on in the outside world so he allows his scouts to post letters through a flap in the city gates. Receptors are like this flap, they allow information to flow into the cell, whilst preventing the molecule that is carrying this information from getting in.

It is this flow of information, mediated by GLP-1 receptors, that causes its effect. The problem is we don’t know what happens with the letter once it gets inside the castle. In real cells, there is a cascade. The receptor will activate a molecule, which will activate a different molecule and then that one will activate a third molecule and so on. This is the part that is still largely unknown because the GLP-1s have been developed relatively recently, with the first human clinical trial for liraglutide only being conducted in 2002. However, it should be noted that a failure to understand the mechanism does not prevent a pharmaceutical from being approved or from being effective. Indeed, the mechanism of paracetamol, one of the most widely used drugs on earth, is still a topic of debate within the pharmacological community.

Despite this, there have been some studies that have suggested possible mechanisms for liraglutide. In general, the proposed mechanism falls under two umbrellas, peripheral and central. This is a little bit of pharmacological jargon that basically means acting outside of the central nervous system (brain and spine) or inside the central nervous system.

Mechanism for the central effects

Just as a reminder, the main central effect of these drugs is hunger suppression. GLP-1 receptors have been found in the brainstem, which is at the back of your head and connects the brain to the spine. The neurons here send several projections to parts of the brain that are associated with appetite and homeostasis. Further studies have shown that the administration of GLP-1s into the brain (third intracerebroventricular administration) causes a reduction in appetite and body weight. This study then went on to demonstrate that blocking these receptors had the opposite effect.

In particular, it has been suggested that the long-term liraglutide treatment stimulates activation of POMC/CART by the projections from the brain stem. POMC/CART are a type of neuron found in the central part of the brain that has been found to reduce hunger, energy intake and food cravings.

Alongside this, there have also been reports of peripherally regulated appetite suppression. For example one study showed that blocking the peripheral receptors caused an increase in food consumption. Similar to the central effects. Consequently, it’s likely that appetite suppression has both central and peripheral elements. However it should be noted that these studies were conducted in rats

However, what about humans you may be wondering? Unfortunately there is not very much research in this area. Probably because of the difficulties of studying living human brain tissue and the recent focus on the use of these drugs for diet suppression. However, one study showed that obese individuals had increased brain responses to pictures of food in the areas of the brain that regulate reward in comparison to non-obese individuals. The experimenters later demonstrated that this heightened response was blocked by administration of a GLP-1 agonist. This supports the view that human appetite suppression is controlled by similar mechanisms to that of rat models.

Mechanism for peripheral effects

Having looked at the central effects, what are the peripheral effects of GLP-1 receptors? These are primarily increased insulin secretion and decreased glucagon secretion, which helps to reduce blood glucose levels. I am glad to say our knowledge of these pathways is better although still not entirely satisfactory.

Insulin is produced by beta cells in the pancreas. GLP-1 receptors have been found on these cells, which allows our liraglutide and semaglutide scouts to get their message to the psychotic king.

It is thought that the GLP-1 receptor activates an excitatory cascade that causes a flood of calcium ions into the cell, which unlike the GLP-1 messages actually cross the castle walls and enter the cell. Importantly, the calcium signals for the insulin to be excreted out of the. Perhaps we could imagine this as a gate being opened to trade with insulin for calcium, a precious commodity, with foreign merchants. After all, the king's greed would probably outweigh his paranoia.

In contrast, it is unlikely that glucagon suppression will be caused by a direct interaction with a GLP-1 receptor. Instead, it has been proposed that GLP-1 agonists activate receptors on delta cells (a neighbouring Queendom), which then secretes somatostatin, which is a peptide hormone. This hormone then inhibits the alpha cells (these are the ones that produce glucagon), which prevents glucagon from being secreted. This can be visualised as the queen sending out an army to suppress the foreign territories with her somatostatin soldiers.

Are GLP-1 receptor drugs safe ?

In the latest review article on PubMed, which integrates several clinical trials, some of which have over a thousand participants, there have been no reported dangerous side effects. However, some people do experience nausea, and, less frequently, vomiting and diarrhea. Importantly, these drugs do not cause a dangerous level of blood-glucose drop even in patients without diabetes. There are some concerns that GLP-1 agonists could cause pancreatic cancer because they cause beta cell proliferation. However, the rate of pancreatic cancers observed in clinical trials was not above the expected rate for the population size. Consequently, it would appear that these drugs are physiologically safe. Having said this, I want to make clear that you should always seek professional medical advice before taking any medication.

Discussion

In summary, it has been established that semaglutide and liraglutide safely cause weight loss in people with obesity. Furthermore, it is likely that this weight loss is caused by a simultaneous suppression of appetite and an increase in insulin secretion. However, I want to make clear that this is not a wonder drug. In most studies a 5% reduction in body weight occurred. This is unlikely to make many obese people un-obese. Furthermore, one clinical trial has shown that when people were taken off the drug, they regained much of the weight they lost.

One year after withdrawal of once-weekly subcutaneous semaglutide 2.4 mg and lifestyle intervention, participants regained two-thirds of their prior weight loss, with similar changes in cardiometabolic variables.

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Instead these drugs have been designed to help people maintain weight lost through healthy eating, exercise, etc. Consequently, it’s clear that this medication alone is not enough. Instead, this medication should be viewed as an aid towards reaching a healthier weight in conjunction with a healthy lifestyle.

Yegor Lisle (he/him) is a UCL MSci Pharmacology student. He is curious about the nature of biology, the origin of life, and the biochemistry of the universe. In particular he wants to understand more about the interface between biology, chemistry and physics.

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Thankfully, most of the world is not living in the fear of rabies. This was possible not just due to treatment of the disease when patients fell ill. In fact, the story is far from it. Collaboration of many different sectors was involved to vaccinate dogs against rabies, educate people about the disease and how they can avoid getting it, and surveillance of the disease in both humans and animals. This is one of the many success stories of the One Health approach.

What is One Health?

The One Health approach recognizes that the health of humans, animals and ecosystems are interconnected. It is an interdisciplinary approach that brings multiple disciplines (medicine, veterinary medicine, environmental science and etc.) to work together at the local, national and global levels to attain optimal health for people, animals and the environment. Health challenges that can be tackled using the One Health approach include communicable diseases (particularly zoonotic diseases), food security and sustainable practices in agriculture. Some of these are explained in further detail below.

Role of One Health in Preventing Communicable Diseases

Typically, we think about communicable diseases as those that can be spread between humans. While that is true, communicable diseases also include those that could be spread between humans and animals and vice versa. These groups of diseases are also known as zoonotic infectious diseases (ZIDs). ZIDs can be caused by bacterial, viral or parasitic pathogens and can be transmitted from wild animals or domestic animals, which includes pets, livestock and poultry. The reasons for the spread of zoonotic diseases are not just limited to the consumption of animal products but also include human activities such as deforestation, urbanization, and local and global travel. All these factors have led to ZIDs making up about 60% of all known human pathogens.

One Health recognizes that ZIDs cannot be controlled just by human or animal interventions. Rather, a holistic approach is required that addresses ecological, biological and environmental factors that drive their transmission. Furthermore, One Health recognizes that ZIDs can have significant harmful effects on human health, animal health and the environment. For example, a flea-borne Murine Typhus is caused by a bacteria called Rickettsia typhi. It is a ZID that typically affects wildlife, like rats and opossums, and can spread to domestic animals, like cats, and humans. While the impact on human and animal health is clear in this case, there is also a potential underlying impact on the environment as the unnatural deaths of a species can lead to an imbalance in the food chain and disrupt essential ecological processes. By taking a One Health approach, a coordinated response can address the health and economic impacts of ZIDs on all three sectors.

Role of One Health in Food Security

A major issue in food security has been the lack of cross-sectoral collaboration across the food chain. As a result, this has hampered disease prevention dramatically. In fact, One Health was largely initiated due to the global outbreaks of avian influenza in the early 2000s, which affected human health as well as the global supply chains of poultry. This accelerated efforts towards a cross-sectoral approach that linked human and animal health, resulting in the creation of the One Health approach.

Today, One Health initiatives have gained support among key national and global policymakers including the World Health Organization (WHO), the United Nations Food and Agricultural Organization (FAO), the United States Centre for Disease Control (CDC) and the European Union with the One Health European Joint Programme (OHEJP). These organizations work together to deal with a multitude of issues, with food security as a key agenda.

Role of One Health in Sustainability

Sustainability has recently emerged to be one of the newer focuses of One Health. Particularly, One Health looks at the unsustainable farming practices which can lead to deforestation, soil degradation and pollution. These would then lead to poorer animal and human health and harm to the environment. It can also contribute to the spread of ZIDs with the increased proximity between wild animals and the humans involved.

An unsustainable farming practice is the overuse of antibiotics in poultry and livestock, which has inadvertently led to antimicrobial resistance (AMR) in pathogens and makes them harder to treat when they spread to humans. In fact, a large number of ZIDs make up WHO’s antibiotic-resistant "priority pathogens", which are 12 families of bacteria that pose the greatest threat to human health. However, promoting alternative methods, such as segregating livestock and ensuring cleaner living spaces for them, require additional resources which not all farmers may be able to afford, especially considering that for the farmers, antibiotics is a cost-effective method to keep their livestock healthy. Therefore, legislation and incentives would play a key role in promoting sustainable farming practices among farmers.

Role of One Health in Preventive Healthcare

From this point of the article, it should be quite obvious that One Health can play a large role in preventive healthcare. Rather than treating diseases when they reach humans, One Health looks at identifying and addressing the root cause of diseases, such as environmental factors and animal-to-human transmission. This can lead to more effective prevention strategies, such as improving sanitation and hygiene practices or implementing measures such as vaccination programs for both humans and animals, including livestock and poultry. With a focus on sustainability, resilient processes and healthcare systems can also be proliferated through One Health.

By working together across different sectors locally and globally, health equity can be promoted, particularly in marginalized communities where access to healthcare and information may be limited. For instance, while Ebola is found mainly in some African countries, it poses a threat to other countries, including affluent ones in other parts of the world. By working together with the One Health approach in mind, countries and organizations have worked together to not only eradicate Ebola in communities but also worked towards preventing further outbreaks, such as by reducing the interaction between wild bats, a reservoir for the Ebola virus, and humans. This was done through numerous means which included education or providing safer food options, especially in poorer communities.

Overall, One Health can play a large part in improving human health, animal health and the environment by acknowledging that these three sectors are interlinked. COVID-19 was a great reminder of the interconnectedness of the three sectors, and how a One Health approach for potential emerging infectious diseases could have prevented the pandemic. The preventive healthcare ideology is embedded in One Health one way or the other and is something that should be pushed locally and globally to prevent future epidemics and pandemics while also promoting sustainability.

Hi, I'm Mayank Goel, a Master of Public Health (MPH) student at Imperial College London and a Bioengineering Graduate from Nanyang Technological University. | LinkedIn

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like to stay in touch and join the conversation, subscribe below!

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“If the proximate purpose of technology is to reduce scarcity, the ultimate purpose of technology is to eliminate mortality.”

Hey ChatGPT, could we get a summary of his argument?

“The author argues that the proximate purpose of technology is to reduce scarcity, which can be seen in how technological breakthroughs allow us to do more with less in both the digital and physical world. The author then makes the logical implication that the ultimate purpose of technology is to eliminate mortality, as mortality is the main source of scarcity. If we had infinite time, speed and efficiency would be less valuable, and thus, life extension is the most important thing we can invent.”

Cool… thanks. Truth be told, nineteen-year-old me would’ve jumped in support of this line of argument, but three years later, I find myself more critical of arguments that reduce all human activity to economic productivity. Admittedly, Balaji’s premise is sound as much of technology has been geared towards the reduction of scarcity. The neolithic agricultural revolution reduced food scarcity. The industrial revolution reduced the scarcity of manufactured goods. The digital revolution reduced the scarcity of information (whether accurate or not is debatable).

However, Balaji’s definition of scarcity is strange. He says “with new technology, one can do more with less” linking reduced scarcity to efficiency, rather than the abundance of resources. But any post-scarcity vision built on increased production efficiency must reckon with Jevons paradox- technological improvements in efficiency are often followed by an increase in consumption due to rising demand from falling costs. In other words, Jevons paradox explains that the invention of more efficient steam engines didn’t reduce the use of fossil fuels, but rather reduced the costs of travel, stimulating demand and counterintuitively increasing the use of fossil fuels.

By no means does this imply that progress is bad, humanity has achieved incredible abundance through technological innovation (just look below). But what we have gained is not entirely positive-sum. Acknowledging our drain of resources from other communities, environments, and ecologies, whether human or not, is crucial for a complete picture of the global economy.

To Balaji, this premise implies immortality is the greatest good. He argues that for immortals, the speed of consumption is irrelevant because they have an eternity to do everything they want to do.

There are a number of problems with this line of thinking, the first and foremost being that speed is only one side of the “production efficiency” coin. The other, arguably more important side is quantity. Perhaps, in an immortal future, I hold no care for my Amazon Prime “put-the-parcel-in-my-hand-the-moment-i-think-about-it” subscription. But immortal me still cares about the volume of consumed goods, especially when the goods are essential like food and water.

This leads to my second point which is Jevons paradox for immortal humanity. An immortal, with zero time cost, has no issue spending time-consuming things they might not otherwise find meaningful. A mortal has to choose their consumption, an immortal can have it all. With the fact that immortals live much longer, this would mean an exponential growth in consumption which any increase in production efficiency would find hard to match.

Add the lives of immortals to our existing population growth and you get a variant of the infamous Malthusian trap where everyone is reduced to subsistence over competition for finite resources. This is doubly true when considering essentials like food, where the volume of consumed goods matters more than the speed.

Contrary to Balaji’s article, immortality seems to increase scarcity if anything. More broadly, in a finite world, with finite access to resources, post-scarcity is a pipe dream. But, it could be argued that more people alive would mean more minds to invent technologies that increase absolute access to resources rather than efficiency (think asteroid mining or agriculture on Ganymede). This seems self-defeating, in this worldview immortality is simply a means to obtain more technology which opens access to more resources. If technology’s ultimate purpose is immortality, then it should logically cease to be useful post-mortality.

The need for narrative

That being said, I don’t entirely disagree with him. Later on in the article, Balaji proceeds to advocate for a revitalization of techno-optimist storytelling. Rahul Rana in his recent article, “Tell Good Stories”, reiterates that point:

We need knowledgeable people to tell Good Stories, to weave together all of the threads of the current state-of-the-art into compelling narratives that help clarify the future. Importantly, they need to help people understand the impact – good and bad, not just bad – that new technologies might have on their lives.

Tell Good Stories, Not Boring

What Rahul and Balaji both hone in on, is the importance (and relative lack) of meaningful narratives around technology. While most people are aware of what technology can enable us to do, we do not know why we should do anything with technology at all.

Notwithstanding the lack of narratives, there are deeper wounds to heal hidden in the public’s mistrust of technology. The last generation of techno-evangelists moved fast and broke many promises that they had made. They have profited off of digital addictions to social networks, deepened ideological divides in society and strengthened governments with digital surveillance tools.

The cypherpunk utopian narratives that were pervasive in 1980s Silicon Valley saw states, ethics, politics and history as enemies to progress, instead preferring a techno-centric worldview. While those narratives are pretty pictures of the world, they fail to account for the complex socio-political world that we inhabit. The reason the public distrusts technology is not that they don’t believe in progress, but because it feels like progress is being made for a few at the expense of the many.

The critical part of the technology narrative is not what we can do, but rather how we can collectively flourish.

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In this situation, the revitalization of techno-centric narratives about “immutable money, infinite frontier, artificial intelligence, and eternal life” (Balaji’s article again), is sure to only prompt scoffs and disdain. The critical part of the technology narrative is not what can do, but rather how we can collectively flourish.

Jasmine Sun puts this rather succinctly:

Systemic problems require systemic solutions. We can recognize that technology is critical to our future without replicating the narrow techno-utopianism of the past. From the beginning, a new left techno-optimism must be willing to engage with social justice, politics, and history in a way that past techno-utopians have not. …. …. we need parallel efforts around imagining better worlds and building the tools, resources, and infrastructure that will get us there. Unlike those of past techno-utopians, these projects can be promising because they start with an understanding of our social, political, and historical conditions before scoping tech’s role.

We should start with visioning: telling stories about who will be included and how; rallying people around technology’s human potentials rather than its abstract technical features. Early science fiction, from Russian cosmists’ writing on spaceflight to Vernor Vinge’s pseudonymous web, catalyzed decades of research and development that turned ideas into reality. Yet unlike these past sci-fi scenes, our visions for a progressive techno-optimism must be shaped by diverse voices.

The Reboot Manifesto

I agree with both Balaji and Rahul, we need more progressive narratives. But the problem with making immortality the goal of technology goes back to my earlier point about how progress is not entirely positive-sum. The pursuit of immortality sounds exactly like something that would benefit a small, elite group at the expense of resources from other communities and environments in the global economy. It is terribly difficult to tell if Balaji wants humanity to be immortal, or just himself. After all, he would be at the front of the line for any longevity technology- “The future is already here, it is just not evenly distributed”.

And this isn’t going to inspire the kind of optimism that I want to see in the world.

Postmodern Vitalism

So, I’ll try to do better. Going back to the agricultural, industrial and digital revolutions, something always follows the rapid increase in productive efficiency. The neolithic agricultural revolution saw the rise of centralized cities, political structures, division of labour, art and architecture. The industrial revolution saw the rise of democracy, capital markets, liberalism, egalitarianism and literacy. All of these features might be summarized as a rise in the standard of living, and a rise in human flourishing. From that lens, reducing scarcity is a means to an end: the proximate purpose of technology is to maximize human flourishing.

I imagine flourishing to be about more than longevity, indeed I believe it is about much more than humans. It comes from the understanding that all flourishing is mutual, that we are part of a beautifully complex system that is bigger than us. It lives in gratitude for the world, and compassionate communities rich with shared meaning. Flourishing is about technology that enables and connects people to do things that they otherwise couldn’t. Most importantly, flourishing is about managing real scarcity and yet living in abundance.

Recognizing abundance rather than scarcity undermines an economy that thrives by creating unmet desires. Gratitude cultivates an ethic of fullness, but the economy needs emptiness. The Thanksgiving Address reminds you that you already have everything you need.

- Braiding Sweetgrass

Flourishing is a path, a trajectory whose final destination is hard to pinpoint. But, when I try to imagine the pot of gold at the end of the rainbow, I think of the word vitality. In Latin, Hildegard von Bingen called it Veriditas: the imperative of humans to grow and spread all forms of life, heal each other and nurture the world around them. Vitality encapsulates not just the pursuit of human flourishing but that of collective flourishing, recognizing that complete physical, emotional, social and spiritual well-being resides in the relationships, not the self.

If the proximate purpose of technology is flourishing, the ultimate purpose of technology is vitality.

A technological telos of vitality might have very similar goals to those outlined by Balaji - “immutable money, infinite frontier, artificial intelligence, and eternal life”. But the context is critical. Vitality calls on us to re-examine our relationships with each other and the world and use technology in ways which empower all of us.

This calls for more than ordinary techno-centrism. In every revolution before, an increase in abundance was subsequently followed by a reorganization of societal values to increase flourishing. But the digital revolution has yet to bring with it such change. EO Wilson put it best when he said:

The real problem of humanity is the following: we have Paleolithic emotions, medieval institutions, and god-like technology. - EO Wilson

Thus the narrative of vitality necessitates an inclusive definition of technology. It reminds us that social, economic and political structures are essential technologies for modern civilization, and desperately need innovation.

Imagine inclusive worlds

To generate a deep sense of shared meaning we must paint a vision for a future that everyone wants to see. A focus on technological progress as the civilizational narrative not only alienates the majority of people but fails to remember that technology is a tool, not an end in and of itself.

To rekindle human ambition we should instead gather around a ‘telos’. Acknowledging vitality as a fundamental good gives us the guiding principle by which to wield the power of technology. With that, we can paint a future that people are willing to fight for.

Special thanks to Jeremy Sim, Nikita Vattas, Andy Tudhope, Ray Schmitz for reviewing this essay and providing insightful feedback and new research directions. Andy also wrote a piece ‘Encouraging Heart’ partially inspired by this that you should check out!

Sudharshan Sundaramahalingam (he/him) is the co-founder of Happily Ever After, where he is building a future for healthcare that is community-centered and focuses on collective flourishing. He spends his spare time brewing coffee, being an amateur philosopher and dealing with his 20s through writing. | Twitter | Website

The Pink Zone publishes articles reimagining the future of healthcare every two weeks. If you’d like stay in touch and join the conversation, subscribe below!

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Perhaps a fitting motto for our species would be ad astra per aspera. However, a star, which is often taken for granted, has had a more subtle, yet no less profound, impact upon the human condition - our sun. This sphere of hydrogen and helium has single-handedly shaped life on earth and would take an entire book to fully explain. But this article shall focus on what is perhaps less considered: the impact of the sun on the circadian rhythms of the human body.

A circadian rhythm is an internal body clock that regulates processes such as sleep and eating habits. The term originates from the Latin phrase ‘circa diem’, which means ‘about a day’.

In particular, this article will follow the path of a photon all the way from the sun, or one of those stars that are lightyears away, to the human eye and ultimately the rest of the body. Through this journey, it shall become clear that light has a profound impact on regulating our circadian rhythms. Importantly, this will show how imbalances in the mechanisms behind these clocks can lead to disease states such as insomnia, Alzheimer’s and metabolic conditions.

Let's embark upon the voyage of a photon.

Disembarking at the Eye

Once the photon has crossed intra or interstellar space, it will enter the eye. One imagines this as the final harbour for lost particles; a great port bustling with all sorts of electronic signals, towering cranes of protein and photons arriving at customs en masse. The arrival of these photons causes the activation of intrinsically photosensitive retinal ganglion cells (ipRGCs), which are a type of cell found on the retina. However, unlike the rod and cone cells in the eye, ipRGCs have no role in vision- they are mere light sensors. In fact, these cells tend to remain functional in blind people, which explains why their circadian rhythms are undisturbed by loss of visual cues.

ipRGCs are excited by the activation of melanopsin photopigments. When a photon hits this molecule, it provides energy, which causes it to change shape and become ‘turned on’. It is then able to activate receptors that initiate a small electrical impulse in the cell. Ultimately, many of these electrical impulses will come together to activate the retinohypothalamic tract (RHT) (this is just a sophisticated way of saying a nerve that travels from the retina to the hypothalamus, which is a structure in the brain). Think of this as a motorway that goes to the brain. However, the photons can’t get a visa to access it. Instead, they pass on the message to electrons, which act as couriers, and drive to the brain in their place.

Arriving in the Brain

The electrons have speedy transport and are soon within sight of the metropolis, the capital city of the body. This particular road (the RHT) leads the electrons to the suprachiasmatic nuclei (SCN) (another structure in the brain), which has been discovered to act as the central circadian pacemaker (perhaps Big Ben might be an apt analogy). In fact, light causes up to 40% of SCN neurons to change their excitability. Although this pacemaker can act independently of the environment, it is beneficial to calibrate it ever so often to ensure that the body’s time is an accurate reflection of real time (i.e. day or night).

The SCN has several roles, one of which is to stimulate the release of melatonin, which shall be returned to later in the article. However, its main purpose is to send messages to the circadian clocks located throughout the body. This is an important concept to understand. The body doesn’t just have one clock but many throughout different organs and even specific tissues. This means that different clocks tick at different rates to reflect the needs of the tissue or organ that it is located in.

Therefore, think of the SCN as a master clock that calibrates other peripheral clocks based on the environmental information provided by the humble photon still caught up with border security at customs. Therefore, our electron couriers are now tasked with relaying their message to tissues around the body. But now, in addition to the rapid electrons, the SCN can dispatch hormones that travel in the slow trucks of the vascular system, as well as causing alterations in body temperature to alter peripheral clocks. As the old saying goes, all roads lead to the suprachiasmatic nuclei (but only as far as circadian rhythms are concerned).

Arriving in the Peripheral Tissues

The electronic and hormonal messengers now arrive in the provincial towns of the body, where life is a little simpler and quieter than the capital. Here they will alter the function of the molecules that constitute the clock, which so far have not been discussed.

**The circadian clocks function via proteins that inhibit their own production**. This can be thought of as a factory that produces robots with a limited number of cogs. The more robots it produces the slower the production becomes as the factory runs low on cogs. The factory then has to wait until the robots break and can be recycled to replenish its stock of cogs.

A similar process happens in the body. It produces proteins via transcription and translation of DNA and then has to wait until the proteins are degraded by processes such as phosphorylation before more can be produced. This ‘waiting’ provides the rhythm of the clock.

The full molecular complexity here is omitted. The take home message is that there are a series of molecules which undergo regular sequences of synthesis and degradation.

Thus, altering the rate at which the proteins degrade (by activation or inhibition of other proteins in the cell) leads to a slower or faster clock.

This, in essence, is what the effect of the SCN is on peripheral tissues, a tweaking of the cellular environment to calibrate peripheral tissues with the external environment and especially light.

These clocks have several important local effects, such as the control of glucose homeostasis by the liver and pancreatic clocks, as well as ovulation by the ovarian clock. It has also been demonstrated that normal activity levels and body weight are achieved by having a functioning circadian clock in muscle tissue.

This leads to the questions of what happens when circadian rhythms fall out of sync.

Effects of Circadian Clocks on Disease

There are several mechanisms by which circadian dysfunction can result in disease. However, this article focuses on melatonin as this pathway is dependent on the photons that initiated this saga.

To understand the mechanism we return to the SCN district of the capital. As has already been alluded to, the SCN is responsible for the regulation of melatonin release.

Although the exact pathway is thought to occur due to the inhibition of melatonin synthetic enzymes like N-acetyltransferase in the pineal gland, the overview is that melatonin production is reduced by light.

Importantly, it has been discovered that the SCN is more sensitive to short or blue wavelength light, which may explain why looking at phone screens before bed reduces sleep quality and duration.

In fact, circadian rhythm disorders include various sleep disorders (e.g. delayed sleep phase disorder, jet lag, shift work disorder). These disorders include several notable symptoms such as insomnia, excessive daytime sleepiness, difficulty waking up in the morning, sleep loss, depression, poor work or school performance, and inability to meet social obligations.

In addition to these neurological disorders, melatonin dysfunction has also been associated with diseases such as Alzheimer's, Parkinson's disease, dermatologic, psychiatric, cardiovascular, and numerous cancers.

Consequently, it is clear that maintaining circadian rhythms is fundamental to good health, in which the seemingly humble photon may play an oversized role.

To be clear, this article is not suggesting that using electronic devices before going to sleep will cause these conditions. However, such behaviour is a risk factor. Consequently, it is advisable to rethink personal routines to include ‘screenless’ time before sleep. This could include reading a book, having a conversation with flatmates or partners, or simply preparing for the next day.

Journey’s End

This article has recounted the journey of a particle that many are unlikely to consider in everyday life but consistently plays a role of singular importance in human health. The readers of this article should possess the understanding of how light leads to the circadian rhythms that regulate the patterns of our life. In addition, it should now become apparent that poor sleep hygiene and errors in the body’s circadian clocks can lead to various pathologies. The ultimate conclusion of this article is to pursue healthier night time routines in order to boost personal health and wellbeing as a form of preventive healthcare.

So next time you look out into the stars, consider the photons that are streaming into your eyes and the effect that they will have throughout your body. We are all connected, we are within a singular universe - not above it, we are mere mortals. Ad astra per aspera!

Car Wash Serviceman: Of course, may I see your insurance policy for car washing please?

Person: Ah, I must have it here somewhere… (rummages through bag). Here it is.

Car Wash Serviceman: Let me check if you have car washing coverage under your policy. (pauses) I'm sorry, it looks like you have a $100 deductible for car washing.

Person: What does that mean?

Car Wash Serviceman: That means you'll have to pay $100 out of pocket before your insurance will cover the cost of the car wash.

Person: Can't you just wash my car without going through insurance?

Car Wash Serviceman: I'm afraid not. All car washes must be processed through your insurance policy to ensure proper coverage and documentation.

Person: Can you give me a quote for the car wash so I know how much I'll be paying?

Car Wash Serviceman: (mumbles something)

Person: I’m sorry what?

Car Wash Serviceman: (mumbles something)

Person: Okay, never mind how do I start the insurance claim process?

Car Wash Serviceman: Great. I'll need you to fill out some paperwork and provide some documentation. Once we have everything we need, we'll be able to wash your car and have your insurance cover the cost.

Person: (filles up paperwork) now what?

Car Wash Serviceman: Now I’ll file this with the insurance companies and we’ll process your claim as soon as possible, you can go home now.

Person: But, what about my car wash?

Car Wash Serviceman: I'm afraid not. All car washes must be processed through your insurance policy to ensure proper coverage and documentation, may I see your insurance policy for car washing please?

Person: I just filled it up for you

Car Wash Serviceman: Did you?

Person: I JUST HANDED YOU THE FORM

Car Wash Serviceman: Can you prove that?

Person: I SAW YOU

Car Wash Serviceman: Ok, no problem! We’ll just need you to fill out some paperwork, and provide some documentation of submitting the form. Once we have everything we need, we'll be able to wash your car and have your insurance cover the cost.

Person: ….

Car Wash Serviceman: …

Person: …

Insurance is deeply intertwined with the delivery of healthcare and emergency services around the world. So, when lifestyle medicine (LM) started gaining traction it seemed intuitive to take an insurance-driven approach to funding these services. After all, if people adopted healthier habits, it would yield insurance companies greater profits due to lower preventable disease rates and everyone ends up happy. Sounds about right?

This could be a grave error. Insurance was designed to protect individuals against high-cost, unpredictable, and rare “black-swan” events. Car insurance does not cover car washes, nor is it used for new tires or routine replacement of brake rotors. In the same sense that car washes are preventive care for cars, lifestyle medicine is preventive care for people: it encompasses a holistic and integrative form of care which aims to improve health outcomes through behavior change.

Using that analogy, it makes sense to explore alternative financial models which can improve access and delivery of lifestyle medicine, without the bottlenecks of the insurance system. One such model will be discussed in this article - Direct Primary Care.

What is direct primary care (DPC)?

DPC is an example of a proactive investment in primary care that seeks to provide transparency and deliver essential services at a lower cost.

In DPC, a transparent contract is created between the provider and patient with a known upfront inclusive cost for a specific set of care needs. This cost typically covers all visits, in person and virtual, well and preventive care, and acute and chronic disease care

- Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine

The DPC framework means that patients have a direct agreement with their care providers and incur a predictable and recurring fee, unrelated to the utilization of care services. This is similar to Software-as-a-Service (SaaS) membership models, as in Netflix and Spotify, which most people are familiar with.

In contrast, the prevalent payment method today would be the “fee-for-service” (FFS) approach, which incurs a fixed cost for a fixed service ($30 for a consultation). Depending on the country of residence, the payer model for the service also varies: the National Health Service in the UK (single-payer), insurance and employers in the US (multi-payer).

To be more specific, the Society of Actuaries defines a DPC service as one that

1. Charges patients a recurring fee to cover almost all primary care needs

2. Does not charge patients per-visit out-of-pocket amounts beyond the monthly recurring fee

3. Does not bill any third parties on a FFS basis for services

Critically, the DPC approach means that physicians can directly support a patient’s personal health goals, without justifying it to a third-party insurer. Additionally, this can be done while maintaining transparent costs for any payor involved.

DPC vs Fee-for-service

n 2019, a survey by the American College of Lifestyle Medicine (LM) showed that 59% of LM practitioners were not being reimbursed for their services, and 34% needed to use multiple reimbursement methods. The fee-for-service model is prone to interference and requires value attestation from external parties, which are not necessarily compatible with a patient’s needs. Especially in the context of complex single and multi-payor attestation systems, these processes take a major toll on both care-providers and patients.

More broadly, despite the acknowledgment of primary care as essential to the Quadruple Aim, many primary care professionals (PCPs) are reporting symptoms of burnout especially in the US.

In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew.

-From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider

The rise in burnout symptoms is commonly attributed to:

1. Large patient panels which increase physician stress and worsen patient experience;

2. Lower pay in comparison to other specialist care providers;

3. Increased administrative burden from Electronic Health Records;

4. Performance-based incomes, which shows far higher burnout rates than in salaried physicians; and

5. Long work hours.

These all culminate in a shortage of PCPs, perpetuating the cycle ad infinitum. DPC doesn’t directly address these challenges, but the idea that primary care should be excluded from insurance and unmediated by a third party appears to rectify many of them.

For health professionals

For health professionals, the ability to run a medical practice that is independent from a healthcare system has a significant impact on freedom and flexibility. With smaller patient panels (between 200-600 in comparison to FFS panels which are over 1000) and longer office visits, DPC allows physicians to focus on meaningful work and deliver in-depth and customized care. The reduction in administrative work from insurance and other non-clinical burdens also eases the time-stress on many primary care physicians.

…. only 26.4 percent of DPC clinicians reported spending greater than 10 hours per week on “non-clinical (paperwork) duties” versus 48 percent of PCPs in the FFS survey group. Nearly 46 percent of this survey’s respondents report working zero to five hours per week on these duties versus 21.3 percent of the FFS survey respondents.

- Society of Actuaries

DPC also provides financial stability, through its recurring revenue model. The stability opens the door for physicians to invest in tools enabling higher-quality care, like telemedicine and behavior change programs. This is especially relevant to lifestyle medicine, as behavior change requires a long-term relationship between patients and care-givers, which is expected to be the default in a DPC system.

For patients

Proponents of DPC claim that it boosts the care experience for patients. Chronically ill patients do show significantly lower inpatient hospital, outpatient hospital, emergency department and ambulatory care utilization rates, when enrolled with high-touch, team-based models of primary care.

These are precisely the models of care that DPC empowers, albeit not directly. One gap in the research around DPCs relates to subjective aspects of care like “provider engagement”, “patient engagement” and “quality of care”. The following word map shows the testimonials from a diverse selection of patients in the Integrated Family Care Practice, but this remains anecdotal and warrants a deeper review.

Additionally, as mentioned above, the development of long-term relationships between care-givers and patients allow for continuity of care while boosting patient adherence to health intervention. These are critical features for both preventive care and the Quadruple Aim.

It is also important to note the DPC does not function as a catch-all replacement for insurance, as it only covers predictable and regular health services. In fact, most DPC clinicians encourage their members to carry catastrophic health insurance in addition to their memberships. This means that patients need to be informed with a framework on how to optimally balance both insurance and DPC payments.

For payors

The analysis of cost in DPC practices proves more tricky. There are observed differences in demographic and health status between DPC and traditional cohorts: DPC patients generally hold a lower health risk score. However, with adjustment for differences in health status, the Society of Actuaries reports that DPC cohorts experience a statistically significant 12.64% reduction in total claim costs.

Providing access to primary care also ensures employee well-being, in the case of employer-paid DPC memberships. An increasingly millennial and Gen-Z workforce demand access to well-being services as a critical component of work compensation, especially given the rise in awareness of mental health conditions. DPC allows workplaces to support their employees in prioritizing personal well-being, while boosting productivity and employee retention.

Criticisms

Design of studies

Critics of DPC raise that any observed reductions in utilization or costs are either “aberrant, due to small sample sizes or are driven by patient selection” (where healthier patients choose DPC).

Although risk adjustment strategies have been utilized in DPC analyses to counteract patient selection, the sample sizes are insufficient for analysis of measures like inpatient admission rates. As mentioned previously, the lack of measures to quantify “quality of care” and “patient satisfaction” makes it hard to assess the impact of DPC on those aspects of care.

Variability

Additionally, there tends to be a large degree of variability in care delivery between DPC practices.

Specifically, and perhaps more than any other primary care model, we believe the effectiveness of the DPC model of care in achieving any of its practitioners’ stated goals depends heavily on the unique training, skills, experience, motivations and care that each DPC physician provides.

-Society of Actuaries

This means that outcomes are highly specific to the DPC clinics themselves, and data obtained from a single clinic is not generalizable. Because DPC clinics operate with more liberty as compared to FFS clinics (with insurance oversight), there also needs to be sufficient regulation to protect patients from any mal-intent.

Scalability

The DPC model is also criticized for being unscalable, as it reduces the number of traditional care providers who would otherwise have larger patient panels. Thus, DPC preferentially improves access for enrolled patients while reducing access for others. This runs against the primary mission for healthcare delivery, which is to expand overall access to healthcare.

However, the Quadruple Aim argues that overworking PCPs through large patient panels is not a better solution. Instead, technology and training could be developed such that DPC can be delivered with fewer physicians and a heavier reliance on a variety of healthcare professionals. In that way, physician time can be optimized in DPC settings by taking a team-based approach which does not centre the physician as the only source of medical expertise.

For health professionals, starting a DPC also requires start-up capital, and knowledge of legal and compliance issues alongside a set of entrepreneurial skills like marketing and technology use. This makes starting a DPC service risky for many providers, although the usage of DPC continues to demonstrate a strong 13% annual growth.

Direct Preventive Primary Care (DPPC)

The application of DPC is an evolving field of study on a financial model which is growing in adoption. There are many gaps in the research on its ripple effects regarding access to traditional primary care, due to a lack of data measuring confounding effects like patient selection. There is also insufficient analysis to definitively show the impact of DPC on the quality of care.

A low-risk approach to test DPC models would be to apply DPC to preventive care. DPPC gives lifestyle medicine practitioners, who have yet to receive widespread recognition from health insurers, the ability to start financially viable health services.

The previously discussed benefits of DPPC enable LM providers to operate autonomously and align incentives between patients and providers to encourage long-term relationships. These relationships are essential for health promotion and holistic behaviour change, which is the goal of LM. This shows a promising path forward to increase access to preventive care.

Testing DPC through preventive care enables data collection and analysis on its market dynamics, to evaluate its suitability for general primary care. This minimizes disruption to existing primary care networks and reduces the risk of unknown, undesirable side effects.

Together, DPC and preventive care point to a financially sustainable framework for delivering LM at scale. It might finally be time to pay for our own car washes.

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Unfortunately, both healthcare systems exist in the same, imperfect world and both are failing their people. The NHS has unbelievably long waiting times to visit both the GP and access emergency services, while healthcare services in the US are unaffordable for many residents, sometimes even with insurance. But there is a healthcare system that has taken the best of both the UK’s and US’s to allow readily available and affordable treatment options for its residents. That is Singapore’s.

Public vs. Private Healthcare

Before delving into Singapore’s healthcare system, we need to take a quick look into what defines the other two aforementioned systems. The UK’s healthcare system, also known as the NHS, is a public healthcare system, where all residents can receive necessary medical services and treatments for free. The funding for the NHS largely comes from taxation and acts as a form of “National Insurance”. The US’s healthcare system is on the opposite spectrum to the NHS, as a private healthcare system. This means that residents have to ensure their own means of funding for healthcare, either by paying from their savings or through their insurance. Economics stipulates that privatization of any industry leads to a faster pace of innovation, and this is indeed proven by the American healthcare system. It is no surprise that the two dominant COVID-19 vaccines were created largely or wholly by Pfizer and Moderna, two US-based companies. However, privatization also leads to a hunt for profits among organizations, and this is what has made healthcare in the US extremely expensive and unaffordable for many.

Is Singapore’s healthcare system private or public?

The answer to this question is neither or both, depending on how one looks at it. The closest thing Singapore has to National Insurance is MediSave and MediShield, which will be talked about in greater detail later on. The biggest difference between the National Insurance tax in the UK and these two “schemes” is that for the former, an individual contributes to the overall National Insurance for every UK resident (with those earning more contributing more) whereas for the latter, an individual contributes to their own medical savings and insurance. But the “publicness” of Singapore’s healthcare system does not stop there. If an individual with low income cannot afford healthcare services, then there are other schemes and provisions (such as Medifund) to allow them to receive the necessary treatment at a lower cost or even for free.

Within public hospitals in Singapore, there are tiers of wards that could be associated with private hospitals. The lower tiers, which are also subsidized by the government for residents, are by no means of poor quality and would easily surpass the standards of many hospitals worldwide. The upper tiers, which include private wards, are largely unsubsidized by the government and therefore the patients pay a similar amount regardless of their citizenship status. These are often chosen by wealthier residents and expats or when it is covered for insurance.

In addition to public hospitals, Singapore also has many notable private hospitals just like the UK. They often cost significantly more than the public hospitals but have much shorter waiting times. This replicates the US in the sense that people pay for medical services directly, or indirectly via insurance, as they require with a relatively high cost but with an otherwise ease of access. It is also similar to the UK’s landscape, where there are public and private hospitals in the same community. But what sets the two countries apart is that while people in the UK go to private hospitals due to the relative inaccessibility of public healthcare, the private hospitals in Singapore are utilized by expats who would have to pay similar prices in public hospitals or the very rich who just want to get treatment as soon as possible. In other wants, excluding expats, Singaporeans tend to use private healthcare for more “want” reasons than “need” reasons than those in the UK.

MediSave and MediShield

Every working Singapore Citizen contributes about 8-10.5% of their monthly salary to their MediSave, with an additional amount also topped up by their employers. This MediSave can then be used for their medical expenses, or even for those of their family members. There is no way for a Singaporean to opt out of this, with the justification that it is designed to help them save up during their working years for their healthcare needs, especially in old age. But unlike the National Insurance in the UK, every penny of MediSave is for the individual’s own medical requirements rather than those of others. This gives a sense of responsibility among Singaporeans to stay healthy and use their MediSave wisely, unlike the UK where residents can choose to practise unhealthy behaviors willingly and then access the NHS with no financial cost.

MediShield, or MediShield Life, is a basic health insurance plan to protect Singaporeans against large hospital bills for life, regardless of age or health condition. This includes hospitalization or day surgery, outpatient treatment and long-term care. MediShield is what allows the aforementioned lower tiers of wards to be heavily subsidized. It can be paid by cash or via MediSave savings and just like MediSave, one cannot opt out of it. The premiums are age-dependent and there are typically many subsidies available for multiple income groups. If one cannot afford it, then the government will foot the bill. In other words, every Singaporean will have MediShield Life regardless. Compared to the National Insurance in UK, the premiums for MediShield Life are close to nothing at a median income level.

What makes healthcare in Singapore so cheap?

Taking a look back at “The Cuban Paradox” article, another country buckling the trend was Singapore, which had a lower GDP per capita than expected compared to the life expectancy at birth. But what allows Singapore to spend comparatively less on its healthcare is multi-layered and would take an article on its own to be explained, hence this is just a quick summary. Firstly, external factors that generally lead to better health such as high education levels and a low level of homelessness are undoubtedly a factor. Secondly, the aforementioned tiered system allows residents to access treatment in accordance to their budget, and hence overspending is reduced. Underspending is also reduced, which would otherwise lead to worse health outcomes in the long-term and eventually more expensive treatment requirements. Thirdly, MediSave and MediShield allow Singaporeans to have a forced “backup plan” when needed that they may otherwise not have, reducing government spending as a whole. Lastly, Singapore has proven a private and public healthcare system can co-exist, not just between hospitals but also within public hospitals with a “private” option. They allow private and public healthcare to challenge each other, while ensuring that the needs of patients are met adequately. This has been achieved by creating a well-balanced and regularly reviewed “semi-free” market.

Preventive Healthcare in Singapore

Ending off this article is the connection back to HEA’s main agenda of preventive healthcare. For any system to allow preventive healthcare, it must not have a backlog of non-elective treatments as the resources would need to be prioritized for those first. With the NHS’s endless backlog, it is currently impossible for the UK to focus on preventive healthcare. As for the US, preventive healthcare outcomes have not been possible at the societal level due to the unaffordability of necessary treatment, let alone for elective treatment. With an ageing population, Singapore has made preventive healthcare a priority. It is also in the position to be able to work towards preventive healthcare and reduce the burden of chronic diseases due to the relative low persistency of the issues the UK and the US have to combat. With continuous effort from the government, Singapore could be the first nation to achieve a truly preventive healthcare model, where people only come in for unforeseeable emergencies or for preventive healthcare services such as annual health check-ups and the necessary early treatment.

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A Brief Introduction to Tea

Tea is one of the most widely consumed beverages. In fact, it’s second only to water in many societies.

It comes in many different varieties and can be consumed in powder, loose, or tea bag form. Matcha is a powdered tea, characterised by an intense green colour and distinctive earthy taste. Studies have shown that Matcha has the highest concentration health promoting molecules of any tea. Interestingly, this is because the tea is grown underneath the shade of bamboo matts, which protects these molecules from damage. A consequence of this is that Matcha tea leaves have a higher number of chlorophyll (a green pigment that plants use to absorb light), which gives the tea its vivid colour. So, next time you sip a Matcha latte on you way to work, don’t forget to thank the chlorophyll.

The Chemistry of Tea

Green tea is host to a plethora of beneficial and biologically active molecules. This includes caffeine, chlorophyll, and polyphenols like catechins. It is these catechins that have been the most widely researched and contribute to many of the health benefits of tea. By the way, don’t be frightened of ‘polyphenols’. Poly is a Greek word for many and phenol means a ring of carbon atoms.

In fact, polyphenols account for 30% of green tea’s dry weight. This means there are roughly 169-273 mg of phenolic compounds per gram of matcha. These are very powerful antioxidant molecules with properties that are similar to Vitamin C and E. These a proteins that remove oxide radicals from the body, which are toxic compounds. In fact, this is what antioxidant means.

The health benefits of catechins are broad and have been implicated in diseases such as cancer, cardiovascular conditions and even COVID-19. But in this article, we are going to look at green tea’s impact on neurodegenerative diseases.

What is a Neurodegenerative Disease?

Neurodegenerative disease can be characterised as the loss of brain function or activity. The WHO has stated that around 50 million people suffer from dementia. 60-70% of these cases correspond to Alzheimer’s disease.

Unfortunately there are no known cures for many of these conditions and this article is not trying to imply that tea is. However, the catechins found in green tea have demonstrated the ability to reverse some of the underlying problems of these diseases. In particular, the following sections outline recent research on Alzheimer’s, Huntington’s and Parkinson’s diseases.

Alzheimer’s Alzheimer’s disease is associated with plaques that form in the brain. They are referred to as amyloid plaques and are essentially a jumble of proteins that precipitate, which means they form a solid mass as opposed to being dissolved. These plaques are toxic and can cause cell death and damage. When this occurs in the brain it can affect neurons, which leads to symptoms of dementia. It’s important to understand that Alzheimer’s is just a special case of dementia. Patients with the disease suffer from memory loss, confusion and disorientation as well as other symptoms.

The polyphenols were investigated as a way to combat the toxicity of these plaques. It was found that one of these phenol molecules called epigallocatechin-3-gallate (EGCG) helped prevent the formation of these plaques. It was also shown to reduce the death of neurons. In fact, one study even demonstrated that EGCG allowed for the recovery of learning and memory in mice.

Huntington’s Currently, it is only possible to treat the symptoms of Huntington’s disease, which include tremors, difficulty with speech and involuntary muscle movements. Similarly, to Alzheimer’s, this disease is caused by protein aggregation. However, in Huntington’s, the protein responsible is called Htt.

After researchers screened 5000 ‘naturally occurring’ molecules they found that EGCG showed the potential to stop protein aggregation happening in early stages of the disease. It was shown that a 40% reduction in protein aggregates occurred. However, this experiment was carried out with yeast. Finally, our marvellous molecule has been shown to reduce the toxicity of the proteins even if they do form.

Parkinson’s Much like the other brain diseases, Parkinson’s is caused by aggregation of a protein, which has the slightly complex name alpha-synuclein. Perhaps you’re noticing a pattern? The main symptoms of Parkinson’s are trembling of hands, slowness of movement and poor balance.

Similarly to the previous diseases we’ve looked at, EGCG has been shown to prevent this protein from forming. This has been shown to protect rat cells from damage.

Maybe Trust Your Mum’s Herbal Remedies?

As we’ve seen, the polyphenols in green tea, particularly EGCG, have many useful properties. We’ve just looked at three different brain diseases where this molecule has helped to treat the underlying cause of the problem. So what’s the delay, why haven’t we become immortal from drinking Matcha lattes? Well unfortunately, a lot of this research has been conducted in animals and not humans. In addition, these studies use isolated EGCG at concentrations that you are unlikely to find in your cup of tea. But that doesn’t mean that drinking tea is pointless. As well as the psychological benefits of taking time to look after yourself, it has a whole host of other molecules that we discussed, which really do help bring down inflammation. It just might not be the cure for Alzheimer’s.

Nonetheless, I hope that the next time you make yourself that delicious green beverage you’ll remember all of the amazing molecules it contains and the fantastic science that it has allowed us to discover.

On a final note, this is the first in a series of articles looking at the health benefits of tea. So, watch this space and stay tuned to ‘The Pink Zone’.

Hi, I’m Yegor 👋. I recently joined the HEA team as a healer. I’m fascinated by biology and chemistry. My goal at The Pink Zone is to introduce cutting-edge research on health in an accessible way. I can’t wait to learn and communicate the wonders of science to you, my dear reader.

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Researchers have identified a few potential causes for this phenomenon such as parasites, pesticide poisoning and poor environmental nutrition. But the cause of CCD is always assumed to be at the colony level, not at the individual level.

In fact in most sources of literature, bee health is always addressed at the colony level. Almost all interventions are administered at the colony level through environmental design, support, tools and systems.

When it comes to colony health, many factors of individual well-being are directly correlated to colony well-being and systemic health issues. But this article is not about bees, and neither is it trying to imply that human health is similar to bee health. But it seems that in social organisms, well-being should be explored at the colony level just as deeply or more deeply that the individual level.

This topic was briefly discussed in The Cuban Paradox, where the Family Doctor and Nurse program, instituted in the 1980s, is often cited as the driver of Cuba’s impressive average life expectancy relative to GDP. Cuba’s public health initiatives specifically focus on community-centered rather than individual-centered care, where care is catered to a local community’s needs.

The shift toward community-driven preventive care is not isolated to Cuba, although to its credit it was the first to test the system on a large scale. For the last decade, many organizations across the world have been pushing for more of this type of care: The Kaiser Foundation, The National Prevention Council, and The British Society of Lifestyle Medicine to name a few. The terminology used differs (integrative healthcare, lifestyle medicine, preventive medicine), but the core principles of these organizations paint the same broad strokes.

They are called the social determinants of health (SDOH) which are various factors of health beyond clinical medicine. The SDOH show that when thinking about well-being, up to 89% of individual health depends on non-clinical factors.

If zip code is a stronger predictor of health than genetic code, then maybe human health is not so different from the bees.

Major categories of colony health (nutrition, oxidative stress resistance, and immunity) were impacted by apiary site - Nature

GoInvo, a healthcare UX agency, illustrates this dynamic in a poster comparing percentage contribution to well-being with the amount of capital spent on it. This diagram would vary between jurisdictions, but generalizes to a systemic overvaluation of clinical services, as opposed to other health factors. These costs are inevitably passed on to everyone, either through taxation, high insurance bills or expensive medical care.

The average 1960 worker spent ten days’ worth of their yearly paycheck on health insurance; the average modern worker spends sixty days’ worth of it, a sixth of their entire earnings. - Slate Star Codex

Healthcare as social support

Clued in by the name, social determinants of health, a large part of healthcare has to do with social support. This means that policies and practices in non-health sectors have an impact on health and health equity. The National Prevention Strategy outlines 4 directions to address the problem areas:

1. Healthy and safe community environments

2. Clinical and community preventive services

3. Empowered people

4. Elimination of health disparities

Other preventive care advocates echo these themes. Happily Ever After, as an organization aims to directly address the first three factors, and advocate for the fourth.

Social support behavioral code (SSBC)

When thinking about social support, it is useful to bring in a framework like the SSBC to understand our current position. The SSBC lists the different kinds of social support that can be provided:

1. Informational Support: direct informational support, advice, sharing of knowledge

2. Tangible Support: goods and services

3. Emotional support: mental health support to deal with situations

4. Esteem support: compliments, validation and motivation

5. Network support: access to companions, presence and care

The existing healthcare system provides strong informational support, and tangible support. It is only just catching up to providing emotional support. Esteem and network support are mostly provided by existing personal friend and family networks.

Critically, right now, most of this support is retroactive, after a diagnosis has been made. In contrast, an approach in line with the social determinants of health pushes these support mechanisms to be proactive. By their nature of being social, a preventive approach is highly dependent on local contexts.

Research should be in dynamic relation with local agents of change in the environment - a recommendation by the National Prevention Strategy

Local health is buzzing

Defining locality

In considering the various contexts that may be relevant for healthcare, it is important to first define the concept of locality. Typically, locality refers to a specific physical community. However, for a web-based organization like Happily Ever After, locality can also encompass cyber-physical spaces.

In today's interconnected world, social structures are often fluid and not necessarily tied to traditional family units or physical locations. People may maintain relationships with individuals they have never met in person, and locality can be understood as networks of people and shared memes rather than a specific physical location. In this sense, neighborhood and community become multi-dimensional constructs existing within cyber-physical space, rather than being tied to a specific physical location.

Health in cyber-physical localities

An effective preventive care program aims to make itself redundant as soon as possible: by providing individuals with the tools and autonomy to apply the techniques of lifestyle medicine. This comes down to the 5 key pillars of human well-being: nutrition, exercise, sleep, mental health and relational health. Some examples of statements reflecting these pillars are:

1. “Sleep 7-8h a day”

2. “Walk 10,000 steps a day”

3. “Eat right!”

4. “Avoid stress”

5. “Loneliness kills”

Easier said than done. The statements lack context but apply broadly and globally, which explains their widespread usage in global health media. To illustrate, the notion of “eating right” is highly varied between people from different socioeconomic, ethnic and genetic backgrounds. The WHO mentions this as well, on their page on healthy diets

Diet evolves over time, being influenced by many social and economic factors that interact in a complex manner to shape individual dietary patterns. These factors include income, food prices (which will affect the availability and affordability of healthy foods), individual preferences and beliefs, cultural traditions, and geographical and environmental aspects (including climate change).

This means that for health guidance to be relevant to a community, the local context must be re-injected into the statement. All of the required context corresponds to an individual’s cyber-physical locality.

• Genetics: influenced by the family network

• Behavior: influenced by peers and social network

• Environment: influenced by physical locality

• Social circumstances: influenced by family network and social network

Observing how the social determinants of health are highly driven by local factors, explains why generic health advice is rarely actionable. Preventive care is complex and personal to an individual and their locality.

Population Health

What colony health is to bees, population health is to humans - an approach of integrative and locality-based care that reduces health inequities, promotes health span and improves health outcomes. The domain of population health also an aspect of the Quadruple Aim, which outlines four goals for any healthcare system, alongside reducing costs, patient experience and caregiver well-being.

Although bee health and human health are vastly different, there is genuine opportunity in exploring the domain of population health in at least as much detail as we have explored bee colony health. It opens new frontiers in how care could be administered, and poses many important questions to our healthcare systems today. How can novel systems balance the resources allocated to each social determinant of healthcare, to avoid overweighting clinical medicine? How could communities be taught the skills to gain autonomy over their own well-being? How could health promotion and communication be contextualized to the locality in which it is delivered?

And how can care be made relevant, approachable and integrated into everyone’s lives? These are questions that Happily Ever After takes to heart and is pursuing while building community-centred preventive care. We believe that experimentation at the intersection of public health principles, technology and health science is key to uncovering more problems, and perhaps even solutions in the domain of population health.

If these questions excite you, join us in our journey to build a community of care that delivers on the Quadruple Aim.

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In healthcare, the conversation of digital infrastructure centres around the storage, sharing, and retrieval of health data. The systems that enable health data transactions, directly influence our ability to build newer forms of behaviour around human well-being. Our earlier article on Data Composability highlighted this potential in reimagining our health data infrastructure.

The goal of this article is to take a deeper dive into the now and look at healthcare data systems that are widely used today. By grounding ourselves in the present, while dreaming about the future, it becomes possible to plot a path toward our vision for a better healthcare system.

Existing System Architectures

There are three main systems at the technological forefront of enabling the exchange of patient health data, namely, The Open Electronic Health Record (openEHR), Digital Imaging and Communication in Medicine (DICOM), and Fast Healthcare Interoperability Resources (FHIR).

The Open Electronic Health Record (openEHR)

openEHR (pronounced “open air”) is an architecture that was designed with 15 years of requirements recorded from multiple standards and projects around the world.

Before the introduction of openEHR, a patchwork of EHR software from different, incompatible vendors formed the backbone of global health data infrastructure. The lack of interoperability in the market meant that the data of patients were stuck on different platforms. This problem has been documented to cause many misdiagnoses and wrong prescriptions which has in some cases led to preventable deaths and lawsuits.

The openEHR system was able to achieve what its predecessors could not. It unified EHRs and EMRs across the healthcare industry and established a standard that brought siloed health data out into an interoperable global platform. openEHR was also designed with extensive requirements research, especially around patient privacy.

The content within an openEHR health record is separate from identifying demographic information which protects patient identities from data breaches. Versioning of modified items and private-key encryption of a hash ensures that the integrity of items is resistant to repository corruption. Authorization to view/modify patient data is regulated through an access list defined by evaluating relevance to the caregiver and the duration of care. Furthermore, the definition of privacy levels can be specified within jurisdictions of use, giving patients the ability to select the level of privacy they desire.

Standard interfaces drive network effects, and the ability to seamlessly synchronize data across jurisdictions drove openEHR adoption globally.

Today, Norway and Sweden, both well-known for high-quality healthcare, rely on openEHR for health data exchange. Other jurisdictions that use openEHR for health data exchange include Moscow and Australia. In Moscow, 670+ healthcare providers facilitate the management of health and social care records for its 12 million citizens on openEHR. In Queensland, Australia, 4.5 million citizens have their healthcare data on openEHR.

Fast Healthcare Interoperability Resources (FHIR)

In 2013, the FHIR’s first publication was revealed, introducing a novel method for health data exchange. This publication described a streamlined interface for third-party applications to interact with an EHR system. For the first time, developers were able to build applications using common web standards which enabled patients to view and visualize their clinical data in new ways.

Today, the Apple Health team leverages FHIR to retrieve and aggregate health data from multiple EHRs all across the United States, creating a holistic health dashboard for patients. Similarly, the CommonHealth Project allows users to import and access their health information globally. Their data storage system is local-first, privacy-preserving and has over 1.5 million users across 55 countries.

FHIR is still actively being developed and used by health agencies in the United States, Australia and Europe. In the United States, the Cures Act requires that all certified Health Information Technology support SMART on FHIR. During the COVID-19 pandemic, up to 500 issuers in 20 states across America started issuing SMART Health cards as proof of vaccination. SMART Health cards were a layer of cryptographic verification built on top of existing FHIR authorization and API systems, demonstrating the versatility of FHIR as an open federated system.

Digital Imaging and Communication in Medicine (DICOM)

DICOM is the standard that has been used to store medical imaging in hospitals around the globe for over 30 years. In the year 1980, before the introduction of DICOM, it was difficult for anyone other than magnetic resonance imaging (MRI) and computer tomography (CT) manufacturers to understand machine-generated images. The National Electrical Manufacturers Association (NEMA) and American College of Radiology (ACR) then kickstarted a universal standards committee to fulfil the needs of healthcare workers and biomedical equipment vendors.

As of 2019, advanced features are still being appended to the protocol, the most recent being a comprehensive improvement to the web service, applications, and video streaming. In its essence, DICOM specifies a non-proprietary data exchange protocol, file format, and structure for biomedical imaging and information. Through the DICOM standard, automatic interoperability between medical imaging systems, management systems (PACS, etc.), and information systems (Radiology Information Systems, Cardiology Information Systems, etc.) can now be easily facilitated.

DICOM is currently used in medical devices for various medical specialities and it is the bedrock of most medical imaging systems all around the world.

The costs of sharing health data

Health data infrastructure has come quite a way since the advent of digital systems. Today, health data is more standardized and accessible than ever while providing convenient and efficient authentication. But, being better than ever does not imply perfect.

In September 2022, the World Economic Forum published an article criticizing major inefficiencies in the global health data system. The COVID-19 pandemic exposed over-centralization risk and coordination failures in health data infrastructure and the article outlines the potential use of web3 technologies to combat these issues.

As discussed earlier, infrastructure plays a direct role in reducing transaction costs for coordination. This implies that there are bottlenecks in existing infrastructure which could be identified to induce these coordination failures.

The Open Electronic Health Record (openEHR)

As seen from the figure above, openEHR stores patient healthcare data information in a shared platform where different healthcare institutions can access the encrypted data in their local jurisdictions. However, it also highlights that while patients might have control of their healthcare data, they cannot access it directly from anywhere around the globe.

For example, if a user were to experience a medical incident while travelling, foreign hospitals would be unable to view their records as all their health data would reside in their home country’s openEHR system. This means that users have a say but no sovereignty similar to data housed in any client-server system.

openEHR also consists of highly complex archetypes: these are “LEGO bricks” that are used to represent core clinical concepts. As these archetypes are maximal, all of them have to be described before implementation, which requires a lot of time and space.

One example is blood pressure data, in openEHR every possible representation of blood pressure is taken before a template is generated based on which archetype elements are needed (systolic pressure, diastolic pressure, the position of the patient, etc.). This makes openEHR very thorough but a hassle for implementations that do not require that level of detail.

Fast Healthcare Interoperability Resources (FHIR)

A recent study by Diameter Health highlights the inability of FHIR to account for data quality as a major bottleneck. The majority of allergy, lab results, and medication information is not coded precisely in EHRs, thus causing a lot of data to be unusable. This means that most data has to be sanitized before it can be parsed by FHIR.

Additionally, FHIR requires an additional translation layer to be reusable across various technologies. This translation is known as FHIR profiling and it is a necessary step for each new FHIR implementation due to its uniqueness. FHIR profiling customizes resource definitions by constraining the elements required, this is done by removing definitions that are not needed. The removal of unnecessary definitions is a time-consuming task but there are many tools (Kodjin, Forge, Trifolia, etc.) that have been developed to ease this process.

Jurisdictions also have differing requirements for key vital signs profiles: blood pressure profiles in the US use specific fields like Systolic and Diastolic pressure, but there are no such requirements in India. This exacerbates data fragmentation as multiple profiles for different jurisdictions have to be created for the same vital sign.

Digital Imaging and Communication in Medicine (DICOM)

As DICOM is a 30-year-old standard that is used for specialized tasks, most major cyber tools do not support the scanning of this file format. In recent years, security researchers have even found vulnerabilities that allow hackers to insert malware to infect patient data and destabilize an entire hospital’s PACS system.

Manual hash comparison can be done before executing the DICOM file but it is tedious and inefficient to compare the hashes of every single one of these files. Furthermore, even if the hash comparison is done automatically, there is a chance that the original hash was tampered with.

Non-technical costs

In addition to the technical costs of health data collaboration, there are many additional issues regarding regulatory overhead and economical incentives that must be considered.

Legal:

Most states have stringent security and privacy policies around health data, which “protect users” at the cost of cross-organization collaboration. These policies often indirectly incentivize data silos and hinder positive-sum interactions between organizations.

Economical Incentives:

In a competitive economy, user data is a precious resource that can be mined for profit. Sharing data then goes against the profit motives of many for-profit health organizations (private hospitals, health tech startups) which results in a lack of adoption of interoperable software systems. This is an example of incentive misalignment, where health outcomes would be boosted if users had sovereignty instead of just say over their health data.

A review of the existing infrastructure shows key areas of high transaction costs in health data transfer. The following are some solutions to tackle these issues:

1. Health data sovereignty, not health data say

2. Newer peer-to-peer digital architectures can fully return data sovereignty to users, enabling health records to be transacted over borders, privately and in a human-centric way. This is discussed in greater detail in our post on health data composability, and we are pioneering an initiative on this front called Habitat Health.

3. Automated Data Sanitization

4. A system that sanitizes data is crucial to make most health data usable. Un-sanitized data might refer to data that contains outdated information, data entered in the wrong fields or filled with duplicates or typos. Self-describing data formats show promise in this area:

One of the ways that organizations can ensure such consistency of data modeling with a multitude of data formats, structures, and sources is by relying on self-describing data models. These models provide the flexibility of schema needed for such a plethora of data types, but still deliver consistency in the modeling for specific applications.

- https://analyticsweek.com/data-modeling-tomorrow-self-describing-data-forma/

1. Open-source encrypted medical file formats

2. An open form of encrypted medical file format developed by the community will likely surpass the incumbents due to the limitations of proprietary software. As of 2022, there are little to no open-sourced encrypted medical file formats present.

This list is by no means exhaustive. Health data is illegible, complex, multi-faceted and highly personal, which makes it a very difficult data type to operate with. At Happily Ever After, we are thinking about this complexity and designing systems to help us improve outcomes in a way that centers health experiences around users.

While coordination failures in health data transactions are a big problem, they should not be considered a silver bullet. The aggregation of health data is a part of a larger puzzle: the problem of telling stories about a patient in an intuitive, human-centric way. Representation of data in visual forms is the key to conveying this complexity to clinicians and caregivers.

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References

Allen, A. (2022, January 7). Why openEHR is Eating Healthcare. Medium. https://medium.com/@alastairallen/why-openehr-is-eating-healthcare-e28bd792c50c

Apple. (n.d.). Accessing Health Records | Apple Developer Documentation. Retrieved 4 October 2022, from https://developer.apple.com/documentation/healthkit/samples/accessing_health_records

Beale, S. H., Thomas. (n.d.-a). OpenEHR-Home. Retrieved 27 September 2022, from https://www.openehr.org/deployments/jurisdictions/

Beale, S. H., Thomas. (n.d.-b). OpenEHR-Home. Retrieved 23 October 2022, from https://www.openehr.org/deployments/jurisdictions_detail/queensland-health

Beale, S. H., Thomas. (n.d.-c). OpenEHR-Home. Retrieved 26 October 2022, from https://www.openehr.org/deployments/jurisdictions_detail/moscow-city-department-of-information-technologies

Chainlink. (2022, May 13). Bela Supernova Awarded Chainlink-Filecoin Joint Grant. Chainlink Blog. https://blog.chain.link/bela-supernova-awarded-chainlink-filecoin-joint-grant/

CommonHealth. (n.d.). About. CommonHealth. Retrieved 22 October 2022, from https://www.commonhealth.org/about

Deloitte. (n.d.). The Future of Global Health Care. Deloitte. Retrieved 23 October 2022, from https://www2.deloitte.com/global/en/pages/life-sciences-and-healthcare/articles/global-health-care-sector-outlook.html

Diameter Health. (n.d.). FHIR and Data Quality. Diameter Health. Retrieved 24 October 2022, from https://www.diameterhealth.com/2022/07/fhir-and-data-quality/

DICOM. (n.d.-a). About DICOM- Overview. DICOM. Retrieved 22 October 2022, from https://www.dicomstandard.org/about

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Editors, T. Pl. M. (2013). Focusing the Spotlight on Lack of Access to Health Information. PLOS Medicine, 10(4), e1001438. https://doi.org/10.1371/journal.pmed.1001438

Fred Schulte & Erika Fry. (2019, March 18). Death By 1,000 Clicks: Where Electronic Health Records Went Wrong. Kaiser Health News. https://khn.org/news/death-by-a-thousand-clicks/

Haleem, A., Javaid, M., Singh, R. P., Suman, R., & Rab, S. (2021). Blockchain technology applications in healthcare: An overview. International Journal of Intelligent Networks, 2, 130–139. https://doi.org/10.1016/j.ijin.2021.09.005

HealthITSecurity. (2019, April 18). DICOM Flaw Enables Malware to Hide Behind Medical Images. HealthITSecurity. https://healthitsecurity.com/news/dicom-flaw-enables-malware-to-hide-behind-medical-images

HL7 FHIR. (n.d.). Profiling—FHIR v4.3.0. Retrieved 24 October 2022, from https://www.hl7.org/fhir/profiling.html

HL7 International. (n.d.). HL7.FHIR.US.CORE\US Core Blood Pressure Profile—FHIR v4.0.1. Retrieved 24 October 2022, from https://build.fhir.org/ig/HL7/US-Core/StructureDefinition-us-core-blood-pressure.html

Maglogiannis, I. (2012). Towards the Adoption of Open Source and Open Access Electronic Health Record Systems. Journal of Healthcare Engineering, 3(1), 141–162. https://doi.org/10.1260/2040-2295.3.1.141

NRC for EHR standards India. (n.d.). FHIR Implementation Guide for ABDM. Retrieved 24 October 2022, from https://www.nrces.in/ndhm/fhir/r4/ValueSet-ndhm-vital-signs.xml.html

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openEHR. (n.d.-a). 7 Security and Confidentiality. Retrieved 23 October 2022, from https://specifications.openehr.org/releases/1.0.1/html/architecture/overview/Output/security.html

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What are the implications of redefining the ideal approach to healing as caring rather than empathic?

First, it challenges physicians to confront their fears rather than circumvent them, promoting personal and professional growth. Second, it taps into qualities that promote listening and learning rather than speculation and assumption. And third, a natural and concrete process replaces one that is laborious and abstract, bringing vitality back to a relationship that is increasingly formulaic.

This is an excerpt from a research paper titled, “From Empathy to Caring: Defining the Ideal Approach to a Healing Relationship”, raising concerns about the use of empathy in clinical experiences. The authors of the paper criticize empathy for encouraging assumptions about the patient’s mental state instead of focusing on understanding and responding to the patient’s direct needs. They describe care as sustained emotional investment in a person’s well-being as opposed to empathy which centres around a clinician’s own emotions.

In The Cuban Paradox, we discuss primary preventive care as being a more joyful and efficient healthcare experience. However, the hidden context behind the Cuban healthcare system, is that it operated amidst communities of care. Cuban life is built around communal living, with strong bonds forged between neighbours, families and friends.

The preventive care system thrives in an environment that is rich with care, and a sense of responsibility for those around you. In that sense, the support required for proactive healthcare was already in ingrained in Cuban culture. At Happily Ever After, our vision is for universal preventive healthcare, and for that, we must first discover how to create (online and offline) communities that are fertile with care.

Love is the ability and willingness to allow those that you care for to be what they choose for themselves without any insistence that they satisfy you.- Wayne Dyer

Humans over centuries as social organisms have evolved highly specialized neural circuitry, to identify different kinds of social interactions: the notion of care is intuitive to many. This is why the concept of care exists universally across people of all faiths, beliefs, social classes and backgrounds. However, taking a step back, is it possible to break down the idea of care to its very essence?

The process of care is a two-entity interaction, from the altruistic caregiver to the recipient. Altruism as seen in ideologies like Effective Altruism is a state of selflessness, with genuine and demonstrated concern for the welfare of others, often at a cost to the individual.

This notion of genuineness is intuitively crucial to care, but without mutual trust between entities, it is impossible to validate that the caregiver is truly looking out for the interests of the recipient. It could be just as likely that they are looking out for their own. Therefore, care acts as a second-order social function, dependent first and foremost on a relationship built on mutual trust.

The evolutionary basis of Care

Built upon mutual trust, is the concept of altruism. Altruism is a social phenomenon not unique to homo sapiens, a popular example is that of symbiotic species like the clownfish and the anemone. The field of evolutionary biology explains these kinds of altruism in organisms through two major theories: kin selection and reciprocal altruism.

The theory of kin selection

The theory of kin selection was detailed in the popular (and often misinterpreted) book Selfish Genes by Richard Dawkins. In short, it refers to an evolutionary strategy originally conceived by Darwin, where there is a tendency for individuals to assist others who share genetic traits with them. This boosts the fitness of the genes held in common by both individuals, increasing the chances that these genes survive into the future.

The resultant selection pressure reinforces altruism between kin and has been quantified by Hamilton’s Rule, rB > C. In this equation, r represents the genetic relatedness between two individuals, B represents the benefit to the recipient and C represents the cost to the altruist. Altruism between individuals is evolutionarily favoured when this inequality is met.

The theory of reciprocal altruism

Reciprocal altruism is a complementary explanation to kin selection which states that an altruistic action with a cost makes sense if the recipient is likely to perform an altruistic action in return with a similar cost in the future.

Selfishness beats altruism within groups. Altruistic groups beat selfish groups. Everything else is commentary. - E.O Wilson

The dynamics of reciprocal altruism play out at all scales in human social relationships. It is deeply intertwined with other profound concepts like meaning, trust, truth, and value: delayed reciprocal altruism has been theorized to be the main motivator for the invention of money.

The illustrated flowchart of reciprocal altruism also highlights the effect of cheating on the behavior of both participants. This links altruism back to trust, just like care, it does not happen in the absence of trust.

Together, kin selection and reciprocal altruism are responsible for many of the coordination problems that the human species has been able to solve. What we call altruism from the big picture lens of evolutionary biology, looks very much like care from the lens of an individual.

Engineering Communities of Care

Equipped with the evolutionary history of care, it is now possible to consider how best to engineer societies that are rich in care. Thankfully, groups that are more caring (reciprocally altruistic) have higher evolutionary fitness than those which are not, therefore, altruistic societies are the evolutionary default.

Reciprocity

Looking back at history, altruism and care are part of the basis of almost all faiths, notably Buddhism.

Many illnesses can be cured by the one medicine of love and compassion.

A similarity across all these faiths is the encouragement of reciprocity, which is a major aspect of indigenous wisdom. Taken in the context of reciprocal altruism, a culture which participates extensively in reciprocal gifting is more like to trust one another and by extension more likely to participate in prosocial, altruistic behaviour.

A culture that values reciprocity creates a community that is rich in care.

Autonomy

Beyond thinking about care in the abstract, as consisting of actions exchanged between two entities, it is important to consider the actions themselves. Not all actions are favours rooted in care, is it possible to define the kinds of actions that are considered caring?

From the lens of evolutionary biology, an altruistic action must transfer value from the altruist to the recipient. This value can take a myriad of forms beyond well-understood concepts like time and money. The problem then is that value itself is subjective: for there to be an altruistic action, there must be a shared understanding of value.

This reverts back to the dichotomy between empathy and care. Empathy is defined as the emulation of another individual’s emotions by putting oneself in their shoes. It is not guaranteed that the emulated value of the altruist matches with the real value to the recipient. In contrast, care places an emphasis on attentive listening and questioning to establish a shared understanding of value, before directly providing what the recipient needs.

Establishing this shared understanding requires the suspension of personal biases and beliefs, striving to respect the recipient’s individual autonomy and engage with their true needs.

This pattern is used heavily in the practice of human-centric design thinking. The Empathise step, despite being called empathising, is an intentional process of questioning and listening to identify the situation that a user is in. Only after that initial understanding is obtained, do design thinkers proceed to identify and solve problems for the user segment.

Self

Altruism and reciprocity exist at many different scales, but the discussion thus far has centred on the scale of human-human interactions. This neglects self-care, which is an important aspect of care in society. Without adequate self-care, individuals are prone to burn-out which is common among care professionals like psychologists and doctors.

To account for self-care requires a different scale of altruism than the one that has been explored. Applying a systems approach to thinking, the entities in altruistic relationships could be anything: in this case, they are our corporeal body (recipient) and our incorporeal mind (altruist).

Applying the dual principles of reciprocity and autonomy as highlighted above, it is important to:

1. Respect the body’s autonomy, to understand how it feels and what it needs to not just survive, but thrive.

2. Practice reciprocity, where fulfilling the needs of the body then allows the body to fulfil the needs of the mind.

Granted, the relevance to evolutionary biology breaks down at this level, but the emergent ideas feel intuitively valid.

Care is mutual flourishing

Exploring the nature of care, first leads to unexpected parallels drawn between human society and the evolutionary strategy of altruism. This article then circles in on the three main components of care: reciprocity, autonomy and self. So what then, is the nature of Care itself?

Care is respect: it appreciates autonomy, and it is a directed feeling towards something or someone.

Care is giving: it may not choose to care but cares anyway and does not expect anything in return.

Care is relational: it enjoys sharing anything whether it is a passion or a weekly meal at home.

Care is reliable: it shows up when you need it the most, and can change a horrible situation into a warm experience.

Care is listening: it doesn’t assume what others feel, it thinks with humility and converses with curiosity.

Care is for self: it feels, breathes, laughs and fills, it sets boundaries around its own well-being.

Care binds humanity together, in a game-theoretic pursuit of greater reciprocal altruism. It is our journey towards mutual flourishing, and by engineering communities that are full of care, we can unlock and unleash latent human potential.

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That is the Cuban Paradox, how can a country with so little do so much for the healthcare of its citizens? Indeed if you look at healthcare spending per capita, Cuba spends nearly half as much as Singapore, and 5 times less than the United States.

With the 1959 overthrow of the Batista Regime, the fledgling Cuban government immediately stated that universal healthcare would become a priority of state planning. This was accelerated by the subsequent embargoes from the United States on essential medical supplies, which drove an increase in disease and infant mortality. Then, in 1960, the revolutionary Che Guevera wrote the goals for the future of Cuban Healthcare in the essay titled, On Revolutionary Medicine:

The work that today is entrusted to the Ministry of Health and similar organizations is to provide public health services for the greatest possible number of persons, institute a program of preventive medicine, and orient the public to the performance of hygienic practices.

Cuba’s focus on universal access to prevention-based primary care was far ahead of its time, it was almost a decade until the World Health Organization (WHO) caught up with the Declaration of Alma-Alta in 1978. This declaration identified Primary Health Care as the key to the attainment of “Health for All”. An excerpt from the declaration reads:

The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

Within the next decade, the Cuban Ministry of Health unveiled a master stroke with its Family Doctor and Nurse program. This program provided individuals and communities with a team of medical practitioners to coordinate medical care and health promotion efforts in their region. Each family doctor-and-nurse office takes care of 20-40 families and forms the first line of defence for community health.

Today, there are over 13000 family physicians, with an impressive physician-individual ratio of 1:2500. The doctor-and-nurse teams live in ministry-provided family medicine offices, and are available around the clock.

These teams monitor different parameters of community and individual health such as environment, medical history, and current health. They even make annual home visits to families for holistic health diagnoses. Through these evaluations, the doctor-and-nurse teams can identify, target and eliminate community health risks.

The Cuban Ministry of Health acknowledges and actively addresses the Social Determinants of Health through a unique policy of holistic healthcare. The hands-on approach to community well-being achieved robust clinical preventive services and some of the highest vaccination rates in the world.

This philosophy of healthcare does not need to be technology-light. Although Cuba is a resource-starved nation, it has held onto its 20th-century healthcare principles and adapted them for 21st-century technology. In 2006, the first national meeting of Genética Communitaria (Community Genetics) was held with over 600 medical and scientific personnel in attendance.

The Cuban approach to 21st-century genomics draws parallels to their family medicine system in the 1980s: 184 regional genetic centres were spread through all the Cuban municipalities to create “a national programme for the diagnosis, management and prevention of genetic diseases and congenital malformations”. Cuban genetic health professionals work and live within the communities they serve, creating a flavour of genetics that is community-first and collectivist.

This is poised in stark contrast to the Western narrative of genetic tools as personalized medicine. Cuban community genetics places little value on identifying genetic risk factors such as the BRCA genes associated with breast cancer. This is partly due to the unaffordability of routine genetic testing, but also because of the minimal utility of the information: there is little recourse available for Cubans identified with these risk factors. Instead, there is a focus on leveraging genetic and non-genetic factors like social context to strive for collective medical action like health promotion and raising awareness for diseases.

In this form, Cuban community genetics criticizes Western personal medicine for biomedical reductionism. By ignoring social, environmental and community factors, personalized medicine risks missing important lived context for holistic human well-being.

Cuba is a model country showing how healthcare outcomes can be achieved even in resource-starved nations, through policies of cost-reduction and prevention-based primary care. The challenges facing humanity in the coming century orbit the realization that resources are finite, in healthcare and otherwise. And countries with ageing populations and healthcare systems at risk of being overwhelmed, such as Singapore, have already started to take inspiration from Cuba by integrating family and community doctors into their healthcare strategies.

Preventive healthcare offers a different perspective on human well-being than our current healthcare system. Cuba demonstrates that model on the world stage, but it remains to be seen how alternative models to public health will complement and rebuild the current paradigm of resource-intensive, reactive healthcare.

Happily Ever After is inspired by the Cuban healthcare system which is why we emphasise a community-first approach to preventive healthcare. Through experimenting with different models of public health, we believe that a better, more efficient strategy for well-being can be unlocked.

We want to create health communities (online and offline) that are joyful, inclusive and seamless. The key lies in avoiding biomedical reductionism and addressing the various aspects of the social determinants of health. For that, we look to the Cuban healthcare system for lessons that move us toward our vision of universal preventive healthcare.

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Apple made a savior in Apple Health. By standardizing the data model, Apple Health allows developers to read and write from a single source of truth for a person’s health data. It provides more than 150 standardized types of health data for any app to use. This creates a positive-sum game where all the apps and services using Apple Health can trade information to outcompete any single isolationist health super-app.

To illustrate, MyFitnessPal, a calorie tracking app can pull step counts from Garmin Connect through Apple Health. Now, it knows exactly how far the user has walked, allowing it to compensate for exercise-burnt calories in its daily recommended intake. Similarly, Garmin Connect knows how many calories the user has consumed, allowing it to provide personalized activity recommendations. This is vertical innovation, where MyFitnessPal specializes in tracking calories and Garmin Connect specializes in activity tracking. Cohesively, they provide a better experience than either could alone.

Apple Health works extremely well with Apple devices and not at all otherwise. To share health data with a loved one, both parties must have access to Apple devices and iCloud. To share data when consulting medical professionals, they must be an “enrolled medical clinic”. And there is no way to view Apple Health data on any third-party website or online service.

Apple controls where the health data lives and where it is allowed to go. It is a walled garden of perfect interoperability, which is what Apple has always done best. Data exports are possible out of Apple Health, but the output of all exports is static. Health data is dynamic, so dead snapshots are only useful for a hard exit from the ecosystem.

That is insufficient for healthcare. Apple Health is a closed-ended ecosystem, a platform that ultimately serves Apple’s motives. Closed-ended ecosystems stifle competition and have the potential for extractive revenue generation, both outcomes are terrible for healthcare innovators. This sandboxes Apple Health's adoption to the existing ecosystem, instead of creating the deep platform-agnostic composability that would unlock the potential of personal health data.

Universally composable health data is the assault which might finally crack the coordination problem that permeates the healthcare industry. Armed with the ability to transcend physical borders, new technologies like Verifiable Credentials and OpenAttestation enable trust at scale. During the pandemic, healthcare agencies worldwide used similar systems to validate digital vaccination records backed by cryptographic proofs of authenticity. This is extensible beyond vaccination records to prescriptions and more generally any medical record.

Like physical borders, composability in health data also transcends digital borders across apps and services. The digital health ecosystem operates like monarchies where companies exercise sovereignty over user-generated health data which remains paralyzed inside data silos. With composability, personal health data becomes self-sovereign and this puts control back in the hands of users. Instead of aggregating health data, applications specialize and provide services and features that they alone are proficient at. These features can be composed and extended as data freely flows between different application “states”.

In practice, a genetic testing company would not need to build an app, it simply needs to write genetic data to a user’s data store along with any proprietary data insights it has generated. The data can be signed cryptographically to allow for future verification of the source of the information. The visualization of that data can be done by an entirely independent dashboard application which is designed to present the data in a human-readable format.

The future of digital health should not be a super-app Empire, it should be a Republic of collaborating applications, each serving its niche well and building a stronger whole. This makes the ecosystem resilient against extractive profit-seeking by any one application or service provider. Niche applications also serve communities better than general platforms, by providing hyper-personalized experiences to target specific use-cases without compromising on ecosystem interoperability.

One approach to achieving data composability is adapters, to transform various data sources into a single source of truth. A few examples of this include beepb00p, who built personal data aggregator infrastructure and Terra, a YC-backed startup.

But the adapter approach has major drawbacks: they are typically read-only without the ability to write updates to data sources, and the burden of integration is on the adaptor provider. In Terra’s example, third-party products lack incentives to write adaptors for Terra as it allows users to leave their walled gardens without providing any upside. Third-party products can also change their underlying data structures suddenly and rug the adaptor which remains unaware and outdated.

Apple Health also achieves data composability but has sandboxed itself into its own ecosystem. Incentive alignment is important here, to create flourishing composable data ecosystems requires the infrastructure to be credibly neutral. A credibly neutral system cannot discriminate for or against any specific people. Apple Health is not credibly neutral because it will discriminate in favour of Apple. In contrast, people build products and services on credibly neutral systems like Ethereum with the trust that the ecosystem will not become extractive in the future.

What does a credibly neutral Apple Health look like? An open-source and collectively-owned health data system that is platform-agnostic. The open-source nature allows all participants to voice concerns over architecture and contribute to the system’s development. The collectively-owned nature prevents extractive revenue generation and treats the system as a public good.

Health Apps can be “local-first” and “client-side”, relying on a self-sovereign health data backpack for data storage. The data backpack also enables credible exit from any application, allowing users to easily move between different products. This creates healthy competition within the ecosystem, reducing the barrier of user acquisition for newer, better applications. A credibly neutral Apple Health would be an open-ended ecosystem.

In Carl Sagan’s Cosmic Connection, he talks about how a civilization’s ability to solve critical challenges to progress, such as avoiding pandemics and solving ageing, is positively correlated to information availability. Yet today, health data is created, controlled and stored by opaque companies and governments. An open, composable health data ecosystem would be the cure to that.

Walk into the future

A new cafe just opened down the street from your house. You peek in, there is an empty table right next to the street-side window. Walking in, you take your seat and see the QR code to the digital ordering system. Itching for some food, you scan it:

“Approve health data request - recommended nutrition intake ”

You approve the request, and the Menu slides into view. At the top, is a delicious salmon steak with cream sauce. You’re running low on protein it says. You scroll down to the coffee section, they must have good cappuccinos. You are on your third cup of the day, the menu gently reminds you.

You sigh and click the decaf option on the checkout. “Next time, I’ll come in the morning, bet they have some interesting coffee beans”, you think to yourself.

At Happily Ever After, we are working on a project called Habitat Health to bring composability and self-sovereignty to health data. Find out more about Habitat Health on our website, and follow us on our socials to stay in tune with any updates!

Want to join us?

Check out our wiki for more details on how you can get involved 🥳.

Other HEA Channels:

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Today, we face a different set of challenges. Namely, the four horsemen of chronic disease:

1. Atherosclerotic disease → comprised of cardiovascular disease and cerebrovascular disease

2. Cancer

3. Neurodegenerative disease → Alzheimer’s disease being the most common

4. “Foundational disease” → a spectrum of everything from insulin resistance to fatty liver disease to type 2 diabetes

   - Peter Attia, M.D from Stanford, physician focusing on the applied science of longevity

These combined cause 80% of the deaths in people above 50 (who do not smoke), far outpacing smallpox and other infectious diseases as the major killers.

These conditions are also fundamentally different than their predecessors, and cannot be easily solved with the existing set of reactive health tools. They are slow acting, degrade individual liberty, and cause a massive amount of suffering for both the victim and their loved ones.

We believe in taking back responsibility and ownership for our personal well-being.

In parallel with the rise of humanity’s new challenges, we are also seeing cracks in our traditional healthcare system through high insulin costs and hospitals profiteering off of health data.

Healthcare also has a notorious coordination problem. We live in a time where Amazon knows exactly what we want but our hospitals still ask us what drug allergies we have. Despite these forthcomings, we continue to blindly trust our institutions and hand over complete responsibility for our well-being to states and corporations alike.

Thankfully, the trajectory of biotechnology in the 2020s is analogous to computing in the 1960s, improving in leaps and bounds, year on year. The reduction in costs of genetic tests is outpacing Moore’s law, there are new innovations in synthetic biology and many fascinating ideas at the intersection of artificial intelligence and bio-monitoring tools.

We believe in vitality being the final frontier for humanity.

If the promises of 21st century biotech, end up under a similar centralized paradigm, the impacts on social inequality would be catastrophic.

We have always preached, prevention is better than a cure, and with these new technologies we are closer than ever to being able to put that into practice. The current healthcare system is designed to mitigate suffering after an issue is found, a preventive and proactive healthcare system seeks to eliminate suffering altogether.

Preventive healthcare is about human flourishing, where health isn’t only about staying alive, it’s about being able to do the things that you enjoy doing for a long time.

Happily Ever After is a decentralized community with a single purpose - to help people live longer, healthier and happier lives.

We are trans-humanists, longevity advocates, biohackers, medical researchers, college students and a plurality of other characters united by a common belief in the potential of human flourishing.

We want to build open-source health tools, products and services to unlock latent human potential.

We dream of a health ecosystem that is positive-sum, collaborative and community-owned.

For now, we are small. But the winds of biotechnology, artificial intelligence and web3 are already starting to blow, and we are setting our sails. Things will change, slowly at first, but then all at once.

Want to join us?

Check out our wiki for more details on how you can get involved 🥳.

Other HEA Channels:

• Check out our website

• Follow our twitter

• Follow our instagram