2018 – “Thrilling Three”

December 21, 2018

2018 will be recorded as the year of “Us and Them” – a textbook illustration of how fear triggers us to cluster.  To partition with the familiar. To seek strength amongst tribe. To emphasize boundaries and seek specificity in who “we are”, while seeking to distance (or protect ourselves) from who “we, are not”.

Fear is powerful and useful. It reminds us of the fragility on which health, peace, and prosperity rest – it heightens the pulse, sharpens our attention, prepares us to react. On fear, we have long relied. Yet in exchange for enabling our readiness, fear must short-circuit our analysis. It removes the time to consider, the chance to challenge the facts and the opportunity to double check our assumptions. Fear’s primary utility is transient and when run on overtime, one must, in Franklin D, Roosevelt’s prescient 1933 inaugural words “must begin to fear, fear itself”.

This year the fear of being left behind, or worse, has triggered populism across the world. Most recently have been our “yellow jackets” of France. Just before it was Bolsonaro winning on the promise to put “Brazil before everything, and God above all”. Or Mexico’s completely new political MORENA party and the resulting presidential win of AMLO. A direct response to the grisly fact that 25,000 Mexicans were murdered in 2017— the highest number ever recorded.  With an estimated 130 political Mexican candidates and other public officials assassinated just during the 2018 election alone. Prior to these we had the 2016 US election and followed just after by Brexit. Both catalyzed by “us vs. them” thinking.

Markets react to fear in humanly ways as well, with rapid reflexes that shift portfolios from risk to value. And as we near the end of 2018 we’ve seen tremendous shifts in market perception along these lines. At the governmental level have been tariffs, the economic equivalent of immigration controls. The US has a long and storied relationship with fear inspired trade policy. In fact, the second bill of the newly elected George Washington was the Tariff Act which imposed strict (and steep up to 60% for silk) tariffs on all incoming products into the fledgling country. Said to be intended, to help pay down the war debt, it was also purely protectionist, as Hamilton was fond of quoting, “this Act is critical to protect our infant industries”. The “we” in this instance was clearly the young and comparably inferior US manufactures and the “them” the sophisticated British industrial complex.

But where does this take us?  It helps to start with evidence. To look for demonstration and to look at what we know to be true, while avoiding the natural reflex to imagine the negative.  To seek and see the positive. Each year I collate and select out three remarkable new innovations that have caught my attention and prompted me to say “wow” that might change everything. These I call my “thrilling three”:

2017, 2016, 2015, 2014

As a reminder in 2017, it was MoBikea rapidly expanding ridesharing platform that a built customer base of over 200 million who averaged of about 30 million (peddling!) trips per day on a fleet of eight million bikes across the world. The equivalent of taking 1.24 million cars off the road for a full year. One year later, the shared-bike trend continues to rapidly expand with new formats like scooters (see below) and an increasing use of environmentally friendly electrification. Next up was WeDoctor, a Tencent Holdings-backed online appointment booking, prescription, diagnosis and payment service. By end of 2017, the company already had 150 million registered users across China. Using their mobile platform, users could both find the most appropriate doctor to handle their needs but also secure an appointment, have immediate access to their medical test results and pay for their services – all from their mobile phone and without the conventional hours of queueing. One year later, telemedicine continues to sweep across the world and will soon to be seen as conventional and “old school” as the home visit. Lastly was Mitobridge – a biotech working on medical conditions that result from inborn errors in mitochondria function as well as looking to find methods to maintain mitochondrial fitness in settings associated with aging, inflammation and the host of conditions that result from cellular atrophy. By January of this year, the Mitobridge had been acquired by Astellas Pharma to help further expedite the advance of these technologies and the “primordial pool” of mitochondrially focused companies continues to grow.

So, for 2018 here they are:

Microbility – We tend to like things to be “in their place”.  We have bright lined parking spots to make sure our cars are tucked in neatly, we have drawers for our folded clothes, and tidily named file folders to keep all things organized (except for that desktop!).  So when we see what seems to be the random array of shared bikes left as is, unowned or unchained, it stirs us up. Yet, behind what might seem to be all the sidewalk clutter, lies one of the most useful new solutions for urban gridlock (and all the resulting CO2 belched by those frustrated drivers) – single person electric transportation.  Nothing beats the dual benefits (health and climate) of a self-propelled bicycle, but they not for all and certainly take much larger footprints on the sidewalk (or parked in the office/home). Then there is the remarkable energy savings and the calculus is simple.  Transportation of anything is all about weight. Given their form factor advantage, e-scooters are highly efficient. By way of example, a typical gasoline-powered car (~4,100 lbs) can travel a little less than a mile on one kilowatt of energy. With the increased efficiency of a typical electric car (e.g. Tesla or Volt) one can travel about four miles on the same amount of energy.  Whereas on an e-scooter that same one kilowatt can buy you more than 80 miles of transport.  Hope to see you, next to me, scooting past that traffic jam soon!

Democracy – In 2018, we have begun to fully grasp the extent to which electronic meddling has become commonplace in elections across the world. And although the format (memes, fake news, alias accounts, etc….) may seem to be new entrants into politics, the tools of propaganda, misinformation and societal manipulation have been commonplace since the invent of elections themselves. What is new, is the scale, potency and cross-border reach that these new e-formats can achieve. And in the yin and yang of all things, technology may have just the counterpoint needed to help re-invigorate our democratic muscles. For democracy to function, participants must believe that their vote matters – democracy relies on engagement. Few things pull us forward more than peer-pressure, and in voting too. Emotions were unusually high for the US 2018 mid-term elections, and mid-term voter turnout was the highest in a century. Aside from emotion, it appears that many where pulled into action by get-the-vote-out tools that allowed individuals to target their contacts with SMS messages that were synced with voter registration databases.  When it comes to voting (and democracy!) it is critical that we maintain interest, even if it takes some technology to “guilt trip us” into caring.

China 1st – While participating in a keynote panel at the 2015 Shanghai DIA Annual Meeting I was asked: “what would be the most meaningful signal that China’s pharmaceutical markets have come of age”. My answer was simple, “when the first/best-in-class drugs are approved – first – in China”, approved here before other regulatory approvals, eg. FDA, EMEA etc.. This will signal that a new dawn has arrived for all of China’s patients awaiting access to the world’s most innovative medicines”.  Just three years later, that day has arrived.  Just this month, China has for the first time approved a treatment from a global drugmaker before any other market, illustrating its recent push to bring in cutting-edge medicines. The product is called “roxadustat”, a new anemia drug from AstraZeneca and Fibrogen.  And this Chinese approval is well ahead of the potential approvals in the other markets. Since 2015, profound change has occurred within China’s regulatory body, the “CFDA” and the roxadustat approval is just one of the many of the fast-moving outcomes that will soon become more and more evident as China’s healthcare presence ascends. Approval is one thing, pricing is another – another critical innovation topic that I have covered a lot this year but will leave further wishful thinking on this one to another day.

He Did It – As “thrilling” as these 2018 stories are, one would be remiss not to mention in, an end of year recap, the “chilling” (if not worse) advances reported in gene editing.  The revolution of evolution represented by gene editing has been reflected on here before. For all its potential, the world’s best minds had made it abundantly clear, “we are not ready to move beyond experimentation, into clinical exploration”. The risks are simply still way too high. The lists of technical (and ethical) concerns still way too long (off-target effects, the likelihood of mosaicism, etc.), the need for explicit unmet medical need/urgency before any clinical attempts could ever be considered. And the absolute need for complete transparency and robust oversight. For reasons yet to be understood, a Chinese researcher, Dr. He Jiankui, appears to have breached the collective trust.  To have inappropriately enlisted participants (disparate-to-be parents) and created the world’s very first genetically engineered twins. Presenting to a stunned group in Hong Kong, He nervously sprinted through his data. Full analysis awaits, but if confirmed the results are at a minimum deeply saddening. With hope and grace, the young twin girls (Lula and Nana) will suffer no long-term medical hardship, but only time will tell. But what must result is a deeper resolve to hold those who exploit the “possibilities” of these technologies accountable until it is abundantly clear how best to ensure they are most effectively and appropriately used. For the privilege and trust bestowed on those trained with these skill sets, they must be expected to understand the resulting responsibilities.

Truly yet another “historic” yet “thrilling (and somewhat chilling)” year. Next up, J.P. Morgan 2019 and reflections on the historical path on which our healthcare innovations have traveled to get us here.

And Happy Holidays to all.