No science is sacred anymore

What happened?

After testing positive for the coronavirus, the Brazilian president Bolsonaro publicly took a tablet of the malaria drug hydroxychloroquine. This drug, however, has not proved effective against COVID-19 and its use against it is not approved anywhere in the world. This move, alongside President Trump’s embrace of the drug, illustrates how politicized research into this drug has become and how a next step has been taken towards the politicization of science as we know it.

What does this mean?

The deconstruction of scientific “facts” has long ceased to be the exclusive province of critical scientists themselves. We’ve seen this with other complex issues, in which there will always be room for doubt (e.g. climate change or 5G) and now we’re seeing it with a relatively straightforward issue such as the effectiveness of (existing) medication. This is partly the result of rushed, and therefore in part flawed research, but mostly of deeply-rooted mistrust in established institutions that, for whatever reason, are suspected of wanting to impede the development of an effective and affordable cure.

What’s next?

From now on, we should be mindful of the fact that any study may be called into question and that this will be increasingly based on the intentions and underlying interests of the researcher. Sometimes, we are right to doubt; we know, for example, that funding, even in medicine research, can influence research findings (i.e. funding bias). However, we seem to be taking it a step further, which is diminishing our shared knowledge base. As a consequence, in the future attempts to combat fake news (and the broader infocalypse) could become even more futile than they are now.

What view of humankind should a health insurer have?

What happened?

Technology-driven insurer Lemonade is off to an excellent start on the stock market. Lemonade is sometimes referred to as the insurer of millennials and presents the textbook example of technological disruption; with a frictionless user experience, direct imbursement thanks to A.I. applications and a playful image, it emphatically seeks to align itself with younger generations’ motivations. This way, it’s building strong customer retention, which is often lacking in the established insurers. According to investors and consultants, the health insurance sector is next in line for disruption by these “insurtechs”. However, matters are more complicated in healthcare and digital innovation could lead to more problems and resistance here that could make customer retention more difficult.

What does this mean?

Tech disruptors often embody a new view of humankind, with different motivations. With its strong emphasis on a cheerful and playful interface, Lemonade is also turning against the image of man as homo economicus and focusing more on the homo ludens; the playing human. This strategy of appealing to younger target groups is, however, a risky one for a health insurer; it’s prone to being labeled as risk profiling geared towards young people with low health risks, which is illegal in many countries. After all, it undermines the solidarity of the entire care system. Furthermore, there’s a taboo against the use of health data and an insurer is only allowed to a limited extent to use it for personalizing services.

What’s next?

And yet, it’s understandable that health insurers want to bond more with consumers and to have a more proactive role in the health of their customers. To a health insurer, more data on patients and treatments equals more possibilities to organize care more efficiently and cost-effectively for society. That’s why insurers are seeking alliances to improve their customer retention through cooperation. Big tech companies are crucial in appealing to the homo ludens and promoting a vital lifestyle. Better adjustment to the services and ecosystem of big tech, as for example Vitality health is adjusted to Apple Watches, appears to be a strategic route. To generate trust and security around health data, insurers are more focused on cooperation within the healthcare domain. Digital companies such as CareVoice or apps such as Stresscoach and MS Sherpa could fulfill an important role for the insurer, but caution remains warranted regarding their revenue model and the responsible use of health data.

Will COVID change young people’s quiet image?

What happened?

The average age of people who become infected with the coronavirus is dropping.  It’s increasingly becoming a disease for young people too, for whom it seems to be becoming more difficult to follow the prevention measures against the spread of the virus. Due to the lack of possibilities for young people to come together in, for example, bars or at festivals, there’s an increasing number of illegal parties being organized, in the U.S. and the U.K., for instance, marked as “superspread events”. Because of these events, contagious attendees, who make up 10% of the total number of infected people, are responsible for 80% of the spread of the virus. In addition, a lot of drugs are used, there are connections with the criminal circuit in organizing these events, serious acts of violence are committed and a huge mess is left behind.

What does this mean?

Younger generations, and Gen-Z in particular, has often been characterized as a generation that, in contrast to the standard view of “today’s youth”, is responsible and virtuous. For example, this generation supposedly prefers to stay at home, use less drugs, have sex later in life and be more environmentally conscious than previous generations. Moreover, in the past years, younger generations have levelled substantial allegations at older generations. Climate change, care and pensions becoming unaffordable or the distressed housing market are all attributed to older generations’ lifestyles, particularly that of the baby boomers. Now that younger generations also appear to be getting their hands dirty by needlessly complicating the way out of this global health crisis, this dynamic might change. Because it’s precisely on these issues that a longer duration of the crisis would have a negative impact.

What’s next?

As we wrote before, young people are hit hard by the coronavirus where work, social activities and future prospects are concerned. And although they’ve begun many constructive initiatives to improve those prospects, this recent development could tarnish their reputation. There have been multiple articles in, among other news outlets, The Guardian, in which young people are characterized as “selfish idiots” who might go down in history as the generation that knowingly aggravated the crisis. Since the behaviors that young people now exhibit are not much different from the behaviors that earlier generations have exhibited at a young age (partying, using drugs, cluttering), this generation may be judged harder on their behaviors than previous generations.

Cell factories

Will our use of microbes enable a bio-based future? It is increasingly possible to use and tweak living organisms to produce food, fuel, drugs and materials. Here, we explore cell factories, or engineered microorganisms, to illustrate the ontological and ethical challenges that we will face in light of the rising numbers of hybrids created by advances in biotechnology.

Our observations

  • Cell factories are single-celled microorganisms, or microbes, whose metabolism is synthetically optimized to produce more energy or different substances. In other words, microbes are viewed as production facilities that are engineered with biotechnology to produce for human usage. Examples include chemicals, food ingredients, biofuels, drugs, detergents, paper and textiles. Whereas modern industries manufacture products on the basis of fossil fuels, these cell factories are the building blocks of a bio-based industry.
  • The advances in biotechnology to engineer microbes and create cell factories are in full speed. The question is whether and when these cell factories will be able to produce at industrial scale and economics, so as to accelerate a bio-based industry.
  • One of the major promises of cell factories is the production of food ingredients, such as lab-grown protein (meat, fish, milk, eggs), lauric acid (to replace palm oil), carbohydrates (to replace flour). In the report ‘Rethinking Food and Agriculture 2020-2030’, the authors argue that microorganisms programmed to produce food, or cellular agriculture, are about to disrupt agriculture as we know it for the next ten years. The reason they believe this is that they have calculated that proteins produced in cellular agriculture will be five times cheaper than existing animal proteins by 2030 and ten times cheaper by 2035. Furthermore, these proteins, they believe, will also be more nutritious and healthier.
  • The driver behind this is the rapid advance of precision fermentation. Fermentation farms, the vessels that facilitate the production of these programmed microorganisms, are production systems that are potentially more energy- and resource-efficient, more stable and sustainable than industrial animal agriculture. Industrial animal agriculture as a matter of fact has reached its limits in terms of scale and efficiency, while the worldwide demand for protein is only rising. This technological development will make the plant- versus meat-based diets distinction irrelevant, as food will neither come from animals nor plants, but from unicellular life.
  • Among the parties working in this field, Solar Foods, whose first commercial factory will be running this year, is an example. But Big Food and chemical giants are also heavily investing (e.g. Dupont) in this area.
  • In the past, advances in biotechnology have often raised fears over unforeseeable risks: are we creating little Frankenstein monsters when engineering cells, living organisms that we won’t be able to fully control? We cannot entirely oversee the consequences of industrial biotechnology using cells as factories.

Connecting the dots

Animals and plants play a major role in our society by providing us with food and materials. For a long time, we have held animals to produce meat, milk, eggs, leather and wool, have grown plants to produce grains, vegetables, fruits and fibers. We have become incredibly adept at optimizing these animals and plants, by breeding them in such a way that they comply with our wishes. Indeed, all animals and plants we see at farms today are the result of a long chain of human interventions. The beginning of domesticating these life forms is considered a revolution in the history of humankind. Thousands of years ago, when we started to keep and breed animals and plants to optimize them according to our demands, the way we co-existed with them also drastically influenced our own lives. It meant that humans were able to quit their nomadic, hunter-gatherer lifestyles and settle in places. The agricultural revolution allowed humans to collect more food per unit area and thus the overall population multiplied exponentially.
With the advances in synthetic biology, we might witness what we could call the second domestication of life forms in history. This might again radically alter how we interact with other life forms. This time, however, the focus will not be on visible life forms, such as cows, pigs, sheep, chickens or plants, but on invisible ones: microorganisms, or microbes. Through strides made in the field of synthetic biology and the insights gained in molecular biology, microbes can now be engineered and optimized to fulfill certain tasks, such as producing certain substances. By reading and writing the genome in microbes, or cells, it is now possible to create so-called cell factories. They are a promising way to replace conventional ways of production, as they can be tweaked to produce the specific type of chemicals, food ingredients, biofuels, drugs, detergents, paper, textiles and other materials we need, considering this can be done on a large scale and with a minimum amount of input. Because there are good reasons to believe this will be possible within the next ten years, the question is: will this domestication of microbes change our relation to other life forms?

First of all, it will raise the question how we should view and treat these new life forms. In industrial livestock farming, animals have not exactly been treated as life forms of intrinsic value, raising animal welfare problems. On huge farms, animals often live and die on a production line, in a sense bred to be production units. This industrial handling of living organisms has been questioned for long. It has alienated us from our living world. The current corona pandemic has been labeled a “One Health issue”, which means it is seen as an integral health problem for humans, animals and ecosystems. We are increasingly aware that fixed categories of “human” and “animal” do not always make sense and that we are not an individual species, but that our wellbeing is determined by our relationships with and dependencies on other species. We look more holistically at our living world rather than as existing of separate categories. But if we want to treat other life forms rightfully, where do we draw the line? The claim can be made that microbes have less intrinsic value than macrobes, but since all macrobes are built on microbes (or individual cells), there is no clear line to be drawn. Indeed, the fact that we are more focused on life forms that are visible to us has led us to the macrobist bias in the philosophy of biology. But if we take microbes to have the same value as macrobes, should we grant them microbial rights? Already in 1977, this scenario was explored in a sci-fi story by Joe Patrouch, showing the consequences of full microbial rights, such as a ban on household bleaches as they kill microbes. But today, legislation for microbial life is not sci-fi anymore. The Swiss Federal Ethics Committee on Non-Human Biotechnology has declared that all living beings, including microbes, have minimal value in themselves, implying that all life forms, however small, will have “rights” to some extent.
The fact that we are intentionally interfering in microbial life forms with synthetic biology more often leads us to the second challenge. How do we see these altered life forms or hybrids? These are times when one can find ever-increasing numbers of hybrids that blur the lines between natural and artificial. Cell factories show the characteristics of life forms, such as metabolism, but are artificially engineered. Indeed, cell factories can be seen within a broader category of late modern technology that is increasingly showing signs of autonomy and agency, like AI. These technologies seem to have a “life of their own”. Yet, there is no clear moral framework for these hybrids to come.
The rapid advances in cell factories lay bare the challenges that we’ll have to respond to in the coming years, in order to decide what a bio-based future will look like.

Implications

  • The rapid advance of the commercialization of cell factories will stir up debate on the moral status of smaller life forms and hybrids. This will again create fears about biotechnologies similar to those surrounding genetically modified crops.

  • Cell factories might have important second-order effects on society. First, cell factories would decentralize production facilities, as they can be produced in vessels anywhere. For instance, fermentation farms can be located in or close to towns and cities. And second, cell factories might help to reduce the focus on chemicals we have in our daily practices – fertilizers, synthetic textiles, carbon-intensive materials and substances – and incite the turn to more microbe-based products.

A liberating vaccine

Insofar as there can ever be a definitive end to the corona pandemic, a vaccine will probably play the most substantial role in this. This is not just a matter of whether there will ever be a vaccine and if so, when, but also of who will be the first to develop it and subsequently who will get access to it. It’s highly likely that this will be a lengthy process, with countries partaking in an extreme form of vaccine diplomacy, and the choices they make will reverberate for years, if not decades, to come in international politics.

Our observations

  • Many dozens of candidate vaccines are currently being developed. Testing and approval procedures are being accelerated and carried out simultaneously as much as possible (e.g. operation Warp Speed in the U.S.). A number of vaccines is now being tested on humans and companies are already investing in production capacity in case their vaccine is approved.
  • An eventual vaccine will not immediately be available to the entire world population. Not even now that major pharmaceutical companies and NGOs are investing tens of millions of dollars to prepare for the large-scale production of vaccines that have yet to be tested. Depending on the type of vaccine that is developed, several factors will determine the production speed. This could pertain to specific equipment, the availability of well-trained personnel and, of course, the availability of high-grade raw materials. Even something as seemingly banal as the availability of medical glass in which to package the vaccine, could be crucial to the speed at which production can be increased.
  • Most vaccines will be developed by large pharmaceutical corporations, possibly in cooperation with universities. These corporations are currently promising that they’ll do their part to achieve a fair, global distribution of their vaccines. This is important to their reputation, and revenue, and they want to avoid becoming a pawn on the geopolitical stage (e.g. by becoming nationalized).
  • Meanwhile, governments will involve themselves specifically in the distribution of scarce doses and they will initially take national societal, economic and geopolitical interests into account when doing so. During the swine flu outbreak in 2009, it became clear that a number of rich countries were only concerned with protecting their own populations and were impervious to appeals for international solidarity. The fact that the Chinese Academy of Military Medical Sciences is involved in the development of a highly advanced vaccine highlights once again the geopolitical importance of a corona vaccine.
  • It’s not surprising that countries believe themselves to be co-owners on the vaccines. Be it directly or indirectly, the state is always involved in processes of innovation: as financier, educator, custodian of infrastructures, etc (i.e. “the entrepreneurial state”). This legitimizes the role of the state as divider on a national scale, but also enables it to primarily utilize the technology for its own population (although every vaccine will have partly been facilitated by knowledge from the scientific community). From a moral perspective, one could, however, also argue that any vaccine is always the result of previous efforts from, and data shared by, the international scientific community and no country could ever be the sole owner of the final vaccine.
  • Uit moreel oogpunt zou je echter ook kunnen beargumenteren dat elk vaccine dat ontwikkeld wordt direct of indirect ook gebaseerd is op eerder werk van de internationale wetenschappelijke gemeenschap en dus nooit het exclusieve eigendom van een enkel land kan zijn.
  • At the initiative of the European Commission, an international consortium of mainly European countries – the U.S. did not participate at all – and NGOs, has raised $8 billion dollars for, among other things, global collaboration in the development of a corona vaccine. The WHO is also developing guidelines for an effective and fair distribution of an eventual vaccine.
  • Not everyone is enthusiastic about the advent of a corona vaccine. The anti-vax movement has campaigned against vaccines in general for years and is also up in arms already over a possible corona vaccine. On the other end of the spectrum, there are those advocating to make these vaccines compulsory.

Connecting the dots

An effective vaccine could definitively end the corona crisis. Worldwide, many dozens of vaccines are being developed and some are hopeful that the first vaccines will be approved this year. This would, however, be unprecedentedly fast and chances of this happening are slim, if only because vaccines can also have serious side-effects (e.g. dengue fever and SARS). Moreover, there are doubts about the actual degree and duration of the protection a vaccine can offer, and mutations of the coronavirus could lead to an existing vaccine becoming less effective. Nonetheless, even if a vaccine doesn’t get approved until next year, or even later, this would be an enormous victory for modern (multidisciplinary) science and would liberate us from the pandemic that’s disrupting our society.
It’s worthwhile to speculate on the question how this process of liberation will take place. In our collective imaginations, there seems to be a notion of a vaccine being hailed as a liberating army that will abruptly end a drawn-out war. This image ties in with the war rhetoric that has been applied to this crisis with abandon (e.g. we’re at war with an invisible enemy and healthcare professionals are on the frontlines). In reality, the approval of a vaccine will be much more like D-Day; the beginning of the end of the battle, but hardly an immediate cease-fire.
This D-Day will probably only take place in the country of origin of the vaccine and, because of its scarcity, it will initially only reach part of the population there, presumably groups such as healthcare workers and the elderly. From that moment, it will still be months, if not years, before both the entire population has been vaccinated and there is herd immunity. This period will be characterized by debates on who is most in need of the vaccine (e.g. nursing staff), who deserves it the most (e.g. based on lifestyle) and, depending on the local care system, who is willing to pay the most. As in the current phase of containment of the pandemic, the debate will oscillate between the importance of public health (i.e. vulnerable groups first) and that of the economy (e.g. hospitality workers first).

On a global level, the question will then be which other countries will get access to the vaccine. Initially, it’s highly likely that the country that developed it will keep production entirely to itself, something Trump seems to be aiming for, but at a certain point, part of the production will also become available to other, friendly or high-paying, countries. By means of licenses, other countries will also be enabled to start their own production. India and China are currently the biggest producers of medicine, mostly developed in the U.S. or Europe, and will be particularly well-poised to start their own production lines. Furthermore, international hackers also seem to be engaged in attempts to ascertain the required recipe.
Depending on which country will be the first to develop an effective vaccine – China and the U.S. seem to be the frontrunners – there will be an extreme form of vaccine diplomacy. Especially China is likely to deploy a possible vaccine to strengthen ties (i.e. soft power) with other countries around the world and possibly also to gain more direct advantages (e.g. better terms in trade agreements). Building on the comparison with World War II, the distribution of the vaccine could even determine the sphere of influence of global power blocs. After the war, Europe was divided up among the allied powers. This could also happen to countries or regions that, for example, become dependent on an American or Chinese vaccine, which would place these countries under more direct influence from their vaccine donors.
It’s no wonder then, that the WHO and European Union are placing such emphasis on global cooperation in the development of the potential vaccines and are attempting to come to agreements about fair distribution in this early stage.

Implications

  • The availability of a vaccine could mean that the economy can go full steam ahead. If several countries are able to “open” much sooner than others, this will lead to large disparities in wealth, which will also impact power relations between these countries. This could result in vaccine nationalism, but at the same time, countries also have an economic and medical interest in a global or regional “liberation” from the pandemic (e.g. in terms of international value chains).

  • The development and distribution of a corona vaccine will have considerable consequences for both national as well as international societal cohesion and cooperation. The eventual vaccine will probably be used as a vector of soft power and possibly also as a more direct means of power.

  • The distribution of a vaccine will also be a stress test for European unity and solidarity. There are several explicitly European development projects, but it remains to be seen whether a possible vaccine resulting from them would in fact be regarded as such or as a national product, with producing countries vaccinating their own populations first after all.

Foodnationalism

What happened?

The corona crisis has significantly increased the risk of a global food crisis. In the past months, trade restrictions have disrupted the logistics of the global food value chain of 8 trillion dollars and as seasonal workers were banned, parts of harvests have gone to waste. This means that a lot of food never reached the consumer. In wealthy countries, this has resulted in empty shelves and shortages at food banks, but for a large part of the global population, and especially in developing countries, it has caused extreme hikes in food prices and led to acute shortages. The food organization of the UN has warned that, as a consequence of the corona crisis, the number of people with acute hunger in the world will double this year, to over a quarter of a billion people.

What does this mean?

The global food system is an infinitely complex, international network of producers, distributors and consumers. The corona crisis has made painfully clear how fragile large parts of this network are. This has amplified the call to safeguard food at a national level. But similar to vaccine nationalism, food nationalism is not the right solution to the looming food crisis now. In fact, for many countries, it’s a pipe dream. The reality is that a lot of countries depend on each other for their supply of food. Singapore, for example, is 90% dependent on food imports and Iraq, formerly the granary of the Middle East, imports more than 80% of its food. The fact that grain-producing countries such as Russia, the Ukraine, Kazakhstan, Cambodia and Thailand are now pursuing food nationalist policies by restricting grain exports, is leading to alarming developments in countries that depend on their grain supply. But food nationalism isn’t just problematic for food-importing countries now. It also affects countries with revenue models based on exporting food, such as the Netherlands.

What’s next?

In the short term, it’s crucial that the international food market continues to function to prevent shortages. In the long term, however, it would certainly be worthwhile for individual countries to look into solutions in the form of shorter and less vulnerable chains and, wherever possible, more local production. Furthermore, the corona crisis could be a warning for countries not to depend on just-in-time delivery as much and to more seriously consider strategic supplies. The EU supplies are only enough for 43 days (12% of annual consumption, contrary to Russia (18%), India (23%), the U.S. (25%), and China (75%)). Europe could draw up a regional plan (instead of every European country fending for itself). Furthermore, the corona crisis could prompt countries such as the Netherlands, that depend on the supply of large volumes of resources and meat for their food exports, to think about a more sustainable revenue model, less geared towards volume and aimed more at knowledge and sustainable agricultural products.

Inequality kills

What happened?

To fight the spread of the coronavirus, many countries introduced measures such as working from home and home-schooling, social-distancing or even strict quarantining. However, these measures, as simple as they seem, are not feasible for all. While many white-collar workers can indeed work from home, people with jobs that cannot be done remotely (taxi drivers, cleaners) have no choice but to keep working, and thus to keep exposing themselves to the virus. Their type of employment literally puts their health at risk. Moreover, these often low-paid and flexible jobs are more vulnerable to be laid off (for instance in retail and hospitality services) in the corona crisis. Also, parents can only teach their kids when they have the ability to stay at home and well-educated parents have better resources to offer their kids high quality learning. This divide creates a deeper rift between kids of different social classes. Furthermore, low-income households are often cramped in smaller housing, limiting possibilities for social-distancing. In short, in developed countries, one’s socio-economic status defines the chance to effectively protect oneself from the virus and to deal with its consequences in everyday life. (Let alone how it affects the less well-off in developing countries, where even water and soap for handwashing are not a given, considering that just 25% of the world population already does not have access to adequate sanitation.)

What does this mean?

At the same time, inequality may be a multiplier for the coronavirus’s spread. As research on influenza has found that in an epidemic, poverty and inequality can exacerbate rates of transmission and mortality for everyone. As soon as this crisis has raised awareness that inequality is not only posing a health threat to the vulnerable, but it is also creating risks for societies at large, which might give momentum to policies aiming at reducing social vulnerabilities, reducing inequality, welfare policies or at least to healthcare-as-a-public-good initiatives. It might spark more foreign aid and support initiatives from developed to less developed countries.

What’s next?

The coronavirus reveals that high trust in Asian countries leads to strategy that is more effective. Interestingly, one consequence of high trust in government is a different role of technology. To battle the coronavirus, the most interesting innovation has emerged from countries such as China (automatic temperature detection, Alipay Health Code) and South Korea (drive-through testing pods, self-monitoring apps). As technology is rooted in cosmotechnics, the current crisis forces us to look beyond the coronavirus to imagine a different technological future in Asia. We can expect Asian tech companies to benefit, as Asian governments and citizens are more willing to experiment with innovative technological solutions to the coronavirus.

The Asian coronavirus strategy

What happened?

As the coronavirus sweeps across Europe and the United States, it seems that Asian countries are handling the crisis more successfully. South Korea deployed mass testing to control the virus and Singapore has recorded zero deaths with one of the oldest populations in the world. To explain the success of some Asian countries, many commentators point to their strong governments and “lockdown” measures. However, South Korea never even locked down its most affected city (cafes, bars and gyms remained open) and Singapore mandated “self-quarantining”. Indeed, we have to look beyond the idea of “strong governments” to explain Asia’s relative success.

What does this mean?

To be sure, not all Asian countries are successfully dealing with the coronavirus. Across Southeast Asia, in countries such as Thailand, Malaysia and Indonesia, the response has been chaotic and disorganized. The strongest responses have been from East Asian countries, including Singapore and Vietnam, in what Bruno Maçães calls the “Confucian cosmopolis”. Largely based on the 2003 SARS pandemic, these countries have deployed “early warning systems” with “fast response policy”. Taiwan, for example, took quarantine measures as soon as the first Taiwanese became infected. Most importantly, besides strong government responses, there is broad-based support in these Asian countries for drastic measures like social distancing and GPS tracking. Indeed, rather than a model for an authoritarian state, South Korea defines its model as a “dynamic response system for open democratic societies”.

What’s next?

The coronavirus reveals that high trust in Asian countries leads to strategy that is more effective. Interestingly, one consequence of high trust in government is a different role of technology. To battle the coronavirus, the most interesting innovation has emerged from countries such as China (automatic temperature detection, Alipay Health Code) and South Korea (drive-through testing pods, self-monitoring apps). As technology is rooted in cosmotechnics, the current crisis forces us to look beyond the coronavirus to imagine a different technological future in Asia. We can expect Asian tech companies to benefit, as Asian governments and citizens are more willing to experiment with innovative technological solutions to the coronavirus.

Corona and the US healthcare system

What happened?

The United States are struggling to contain the Corona outbreak as its government has little oversight over actual infections and the spread of the disease. One reason for this, some have claimed, is that the millions of Americans with no or limited healthcare insurance are reluctant to see a doctor or take a test when they show (mild) symptoms of infection. They are afraid of medical bills for tests, further treatment and the costs of quarantine measures. At least one patient already received a bill for more than $3.000.

What does this mean?

In contrast to some of China’s more drastic measures, e.g. locking down entire cities, most Western nations take a relatively relaxed approach to fighting the virus outbreak. All of this centers around early detection of individual cases and monitoring those who they been in contact with. In the US testing took off slow due to manufacturing problems and a lack of clarity with respect to the coverage of costs. Only last week did several states and private insurance companies announce they would cover all costs of testing (still leaving the uninsured with no coverage at all).

What’s next?

Healthcare is already a major theme among the Democratic Presidential candidates with Bernie Sanders pushing for a national health insurance program and Joe Biden seeking to restore and strengthen Obamacare. The Corona outbreak, when it escalates further, could very well sway more Americans to support a more inclusive health care system. Not only because it would benefit currently uninsured individuals, but also because of collective interests in a healthy and well-monitored society.

The (un)changing doctor-patient relationship

Sapere aude, the famous phrase of Kant generally translated as “dare to know”, could be marked as the institutional start of democratization during the Enlightenment. Man rid himself of his immature beliefs and grounded his life in reason and argument. In the following two centuries, this self-liberation of citizens led to empowerment in most cultural, political and economic institutions. Remarkably, health institutions stayed significantly behind. Healthcare became institutionalized and more widely available, but when it came to understanding our own health, all citizens remained laymen, helpless when confronted with illness. Therefore, scholars and physicians have repeatedly advocated the democratization of the doctor-patient relationship to empower patients and promote their self-reliance. With the advent of digital health and the internet, the empowerment of patients seems to be partially achieved, but not every part of the relationship can or should be democratized.  

Our observations

  • The internet is a great source of health information but searching for an explanation of our symptoms can be a real hassle. Healthcare start-ups such as Ada are trying to address this problem. The company has created an AI-powered tool to help patients with their self-monitoring and health management. Once you have typed in your symptoms and answered a series of questions, the AI calculates and displays the likelihood of possible diseases, based on a growing database that matches your age and gender. The app makes clear it doesn’t officially diagnose, but only supports the process of self-monitoring. 
  • In the digital age, self-tracking for health is no longer the exclusive province of chronic patients or fitness geeks but has become widespread. Almost every smartphone OS has apps to make basic measurements in the background of our daily life. Consequently, even without explicit health goals, we’ve all started to collect valuable health data. On the one hand, these new flows of data have resulted in digitally engaged patients and have increased their autonomy. On the other hand, health data is often privately owned and part of wider disciplinary programs or monetization strategies from companies or states, which does not always empower patients.  
  • Nowadays, placebo effects mainly have a negative connotation, as they are associated with false clinical results. However, according to this article, this reputation is slowly changing. Instead of debunking the non-medical effects, we should embrace the psychological effect of placebos in medical treatments. The underlying argument is that emotions trigger biological processes and should not be seen as something separate or non-relevant. These triggered interactions of neurological, immunological and hormonal processes interfere with medical treatments and could strengthen or diminish their effect. In other words: medical treatments would be more efficient if doctors were aware of the importance of attributes that evoke positive emotions, such as trustworthiness, intimacy, authority, wisdom, etc. Not as something important besides the medical treatment, but as an inherent part of it

Connecting the dots

For more than half a century, scholars have envisioned and advocated the democratization of the doctor-patient relationship. In short, it means the shift from paternalistic doctor-centered medicine to more democratic and patient-centered medicine. While the first is characterized by authority and knowledge asymmetry, the core principles of the second are equality, mutual participation, long-term engagement, the patient-as-a-person (instead of a biological reduction), and shared decisionmaking. These principles should result in clear benefits for the patient: empowerment, autonomy and, importantly, better health outcomes, because who knows the patient better than he knows himself. 

Although the scientific discussion of democratization can be traced back to the ’50s, in the last two decadesdigital health has enabled the empowerment of the patient. It started with the internet and Google. Information about health and disease is only a few mouse clicks away. Within minutes, patients can acquire information about any symptom or disease. And then wearables arrived on the market. To measure is to know. Endowed with wearables and dwelling in environments packed with sensors, citizens now continuously collect health data, monitor biometrics and self-diagnose disease. As well-known cardiologist Topol describes in one of his latest books, the patient is evolving into a sort of COO of his own health

The rise of informed, connected and engaged patients in the daily practice of healthcare has also evokedcriticism of democratization. Physicians who once strongly advocated it have become more reserved because they see patients turning away from expertise, demanding second opinions and overly trusting data. Furthermore, scholars are questioning whether we really want patients to interpret their health datathemselves and stress that we should take into account how this will affect them mentally. All in all, having more digitally engaged and participatory patients is undeniably beneficial to healthcare. Yet, some nuance and differentiation are warranted

First of all, neither of the terms in the equation refer to fixed entities, which means “the physician” and “the patient” don’t exist. Naturally, some relationships might become more democratized than others. A lot of severe conditions demand expertise and clinical interventions, which leaves less space for participation. However, in the treatment of chronic long-term diseases such as diabetes, shared decisionmaking and engaged patients can be extremely helpful. The same holds true for the minor illnesses and everyday care general practitioners and nurses are often occupied with. For them, having well-informed and engaged patients constitutes a good starting point, eases the conversation and speeds up the care process. 

Second, health and disease are becoming more complex and multidimensional. For instance, comorbidity (i.e. when someone is diagnosed with multiple diseases or conditions at the same time) is occurring more frequently and will be one of the main challenges of 21st-century healthcare. In light of the above, it is tempting to perceive democratization as a fruitless campaign with anything more complex than a simple virus or cold:patients simply haven’t studied medicine for eight years. Still, it might be useful to reflect on the participatory role and think about what we can reasonably expect from patients. For example, the mere process of collecting health data and monitoring biometrics, without interpreting the data, is already meaningful. Patients can manage their health database and preselect important metrics, perhaps supported by Artificial Intelligence. This patient-AI alliance could focus on selecting risk factors, early detection, and disease prognosis. The doctor arrives at a later stage. In this scenario, democratization is not so much direct empowerment of the patient, but a telehealth feature that mainly serves to streamline care paths. The ultimate challenge here will be to keep false positives within manageable rates. With everybody connected and always monitoring, we might prevent more, but also detect more, and time is one of the most precious assets in healthcare. Besides the cost of overdiagnosis, it also worries people unduly.

This brings us to the third point of nuance. In the ultimate sense, democratization refers to the ideal of a mutual and equal relationship with minimized knowledge asymmetry. However, the role of physicians far exceeds their knowledge, they are “healers” in the broadest sense of the word. Healthcare is the sum of effective therapy and moral care. Physicians and nurses always transcend the medical practice in a way. They listen to the patients wishes or worries, guide them through their illness and thereby help people reconcile with their disease. In this context, an unequal and asymmetric relationship isn’t problematic but instead beneficial for patients. It is about the doctor we trust and rely on, and who has a special sort of spiritual or even religious air about him. Furthermore, all his words, procedures or his mere presence could elicit placebo effects. Consequently, the “disenchantment” with the doctor as a result of overly enlightened citizens could undermine the mental care provided by physicians. Of course, the (placebo) effect of healers is modest with most major medical conditions, but especially in long-term chronic disease management, mental healthcare, and psychosomatic pathologies, this beneficial side of an asymmetric doctor-patient relationship should not be underestimated.  

To conclude, if we want to fully reap the benefits of democratization with engaged and well-informed patients, the doctor-patient relationship first needs to be differentiated and dissected. Subsequently, some parts of healthcare systems could be democratized while other parts remain untouched.

Implications

Higher health expectations of demanding patients and extremely engaged health citizens might eventually result in a sort of boutique healthcare, comparable to the currently rising “boutique fitness”. However, part of this trend is the loss of middle-market companies, only very expensive small boutiques (e.g. David Lloyd, Saints and Stars, and Gustav Gym), and low-cost mass-market gyms (e.g. Fit for Free and Basic fit) will survive in this market segment. It is questionable whether this outcome is desirable for healthcare. 
With the advent of digital health, who becomes in control of which health data has become a pivotal topic of debate dividing stakeholders and scholars. Topol argues that if we really want to realize the benefits of the digitally engaged patient, we should give patients the right to own their medical data. He points to blockchain technology and cooperative organizations such as HealthBank to support this transition. By contrastinteroperable data systems and integrated services are perhaps best developed and operated by big tech companies such as Apple.