Public Health

Catherine Mohr: Medical Research, Technology and Innovation

She calls herself “a tinkerer at heart.” And ever since Catherine Mohr walked into a Boston-area bike shop looking for a high school job repairing drive trains and spokes, the New Zealand-born surgeon and inventor has taken tinkering to a mind-boggling high art here in Silicon Valley.

Dr. Catherine Mohr is the Director of Medical Research at Intuitive Surgical, the global technology leader in robotic-assisted minimally invasive surgery. In this role, she evaluates new technologies for incorporation into the next generation of surgical robots. In addition, she is a Consulting Assistant Professor in the department of Surgery at Stanford School of Medicine where she works in the development of simulation-based curriculum for teaching clinical skills. She is also a Medicine Faculty at Singularity University and an Advisor in the Future of Health Systems Working Group of the World Economic Forum.

Dr. Mohr received her BS and MS in mechanical engineering from MIT, and her MD from Stanford University School of Medicine. During her initial training as a mechanical engineer at MIT’s AI Laboratory, Mohr developed compliant robotic hands designed to work in unstructured and dynamic environments. Later, while pursuing an MD degree at Stanford, she identified needs for new laparoscopic surgical instruments and collaborated to develop the first totally robotic roux-en-Y gastric bypass, and invented and then started a company to commercialize the “LapCap” device for safely establishing pneumoperitoneum.

She has been involved with numerous startup companies in the areas of alternative energy transportation, and worked for many years developing high altitude aircraft and high efficiency fuel cell power systems, computer aided design software, and medical devices.  She spoke twice at TED Conference. At her TED2009 Talk, she tours the history of surgery, then demos some of the newest tools for surgery through tiny incisions, performed using nimble robot hands. At her TED2010 Talk, she walks through all the geeky decisions she made when building a green new house — looking at real energy numbers, not hype.

To learn more about her works, please visit her official website.

The following is an interview with Dr. Catherine Mohr about Medical Technology, Innovation and Creating a Better World. The interview has been edited for brevity.

Niaz: Dear Catherine, I really appreciate you taking time to join us at eTalks. I am thrilled to have you.

Catherine: Thank you for the invitation, it is great to be here.

Niaz: You are the Vice President of Medical Research at Intuitive Surgical, where you develop new surgical procedures and evaluate new technologies for improving surgical outcomes. You have profound experience and a body of great works in the field of Medical and Disruptive technology. In addition to that you’re very passionate about the futures in science, technology, engineering and mathematics. At the beginning of our interview, please tell us a little about your background and how did you get started?

Catherine: I am originally from New Zealand and grew up in Boston. Although, you can’t infer either of those facts from my accent. I always knew that I wanted to be a scientist, but my path to medicine wasn’t typical. As an undergraduate, I majored in Mechanical Engineering and built and raced solar cars as part of MIT’s team. That led me to working in alternative energy with Paul MacCready at AeroVironment working on hybrid electric cars and fuel cells. It was a wonderful time, and I remain very committed to sustainable technologies – encouraging kids at every opportunity to consider careers in science and engineering.

Niaz: Tell us about the road that led you to the world of robotic surgery. It was not a straight path, it seems.

Catherine: It wasn’t until after many years of working as an engineer that I went to medical school. I was in my 30s, and hardly the typical medical student. In many ways, I ended up in medicine because I was very interested in getting back onto the steep part of the learning curve. I loved engineering, but I had become an engineering manager, and I was looking for a new challenge.

In medical school, I was doing a lot of research in surgery and surgical technologies as part of my schooling. I encountered the da Vinci Surgical System and I started doing procedure development with one of my attending surgeons. We both work for Intuitive Surgical now – she as the Chief Medical Officer, and I am the VP of Medical Research.

Niaz: Intuitive Surgical is a high technology surgical robotics company that makes a robotic surgical system. Today, Intuitive Surgical is the global leader in the rapidly emerging field of robotic-assisted minimally invasive surgery. We would like to learn more about Intuitive Surgical. Can you please tell us about Intuitive Surgical, its current projects and also how it has been innovating our future?

Catherine: The flagship product at Intuitive Surgical is the da Vinci Surgical System. It allows a surgeon to operate with full dexterity and capability, but through tiny incisions. The da Vinci System has been a major part of the increase in the rates of minimally invasive surgery in many types of procedures where surgeries were too complex, intricate or just too fatiguing. As of early this year, we estimate that there have been two million procedures done worldwide with the da Vinci System.

Current research and development projects at Intuitive Surgical are aimed at increasing the capabilities and decision making resources of the surgeon while continuing to decrease the invasiveness of surgical therapies. The goal is always working toward better surgeries that are less invasive.

Niaz: The da Vinci Surgical System is a sophisticated robotic platform designed to expand the surgeon’s capabilities and offer a state-of-the-art minimally invasive option for major surgery. It has been using all disruptive technologies like robotics, high- definition 3D camera and so on. Please tell us what is the da Vinci Surgical System and how does it work?Catherine: Although it is often referred to as a “robot”, a more appropriate description would really be “telemanipulator,” as it doesn’t make any autonomous decisions of its own. To operate the da Vinci System, the surgeon sits at a console which has both a 3D display and a pair of input devices, which capture the motions of the surgeon’s hands and the da Vinci System moves the surgical instruments in a precise, scaled replica of the motions that the surgeon is making. This is coupled with a 3D camera so that the surgeon sees the instruments in the display superimposed over where they feel their hands to be.

Sitting down at the console, moving these input devices, and seeing the instruments move exactly the same way is the “intuitive” part of the process.

Niaz: How is robotic surgery, using something like the da Vinci system, better than the old-fashioned way with human hands?

Catherine: The human hand is rather large – at least when you are thinking about making an incision in the body large enough to fit that hand through. The da Vinci instruments are only 8mm in diameter, so they allow you to bring all the capability of that human hand into the body, but through a small incision. This is much better for the patients, as they get the same operation inside, but they heal more quickly with less pain.

Niaz: If we look at the evolution of surgery, we can see really huge changes have happened since last the two decades. With the rapid acceleration in human-machine interaction, the potentiality of robotics in surgery is going to be very vast. How can innovations like robotic-assisted surgery change the world of surgery?

Catherine: The changes haven’t only been happening on the surgical side. The improvements in surgery will come partly from synergies with advances in other parts of medicine. Some of the most exciting things that I have seen have been improvements in diagnostics and screening. As we find cancer earlier and earlier when it is easily cured surgically, we won’t have to do huge reconstructive operations to restore the function that would have been lost by cutting out the larger tumor. This gives us the opportunity to further reduce the invasiveness of our surgical therapies by moving to even smaller incisions, or going in through the mouth and avoiding external incisions entirely.

Niaz: What do you see as the future of robotic surgery? What are our core challenges to reach to that future?

Catherine: As we look at reducing invasiveness, we always want to be able to build things smaller while maintaining strength and precision. Interestingly enough, some of the biggest advances in robotics may come from new material science and machine tools.

Niaz: As an expert in the fields of robotic surgery and sustainable technologies, you’re passionate about realizing the potential benefit that appropriately applied technologies can have in our society, and inspiring the next generation of scientists and entrepreneurs to tackle the world’s important problems. Can you please tell us about some interesting and tough technological problems that you want next generation of entrepreneurs to solve?

Catherine: Apart from the new materials, many of the opportunities to do extremely small interventions will rely upon being able to navigate within the body – like having a GPS for the body. Today, we can map the body with things like CT or MRI imaging, however, the body does not stay static. Organs move constantly, which makes navigating with a preoperative image like trying to follow a GPS map while the roads are constantly changing and moving, but your map never updates. Solving these problems would make it easier to make surgery even less invasive.

Niaz: As you know, it’s really hard to do scientific breakthroughs, to build companies like Apple, Google, Space X, and Tesla, to do something in massive levels with truly disruptive technology. I would like to hear your ideas on doing breakthroughs, coming up with authentic disruptive innovation and on building next big organization?

Catherine: It is solving problems that matter that is the key to these disruptive companies. The problems that matter also tend to be hard, so you need to be patient, and dig deep into the technology to get to solutions. None of the companies you mention are short on ambition, they all started fairly small, and they are deep experts in their technologies.

Niaz: Do you believe Silicon Valley is still the best place to build next big technology company?

Catherine: It is the best place because its historical success has led to the intense concentration of tech talent. However, the shortage of housing and the resultant astronomical housing prices make attracting people to come to Silicon Valley who aren’t already here rather difficult.

Niaz: What does actually make Silicon Valley very special?

Catherine: Critical mass. The concentration of talent, and the expectation that you will fail a bit before you succeed continues to attract the ambitious with big ideas. People cycle through startups gaining experience, and they keep going until they do succeed.

Niaz: You’re a medical technology pioneer, a mechanical engineer, and an expert in robotic surgery. Prior to going to medical school, you worked in the field of alternative energy transportation and sustainable technologies, working for many years with Dr. Paul MacCready at AeroVironment developing alternate energy vehicles, high-altitude aircraft, and high-efficiency fuel cell power systems aimed at reducing our world’s energy consumption and emissions. Can you tell us about how do you connect all of your skills, expertise, ideas and knowledge to break through the threshold in any specific field to get the best out of it or build the big things?

Catherine: Much of what I do involves understanding how the problems we are trying to solve are part of large interconnected systems, and thinking about optimization across the entire system. Optimizing only one part of the solution at the expense of the other important parts is counter-productive. For example, maximizing energy storage without considering weight for an airplane, or improving surgical capability without making it easy enough to operate safely. The big interconnected problems I like to tackle involve many of the same skill sets, even if they are in far flung areas like sustainable energy and surgery.

Niaz: How beneficial is it to have a multi-dimensional background and expertise?

Catherine: Attempting to solve all of these big programs are always team efforts. The myth of the lone inventor is just that – a myth. You need huge diversity of skills on a team, but that very strength means that teams often have difficulty communicating, if the background and experiences of the team members are too different. The people who have experience, background and training in several fields act as the linkers and translators within teams. I like to joke that I am “trilingual” – I speak Geek Speak, Medical Jargon and English – three mutually unintelligible languages. Being able to explain the clinical to the technical and the technical to the clinical is a valuable role.

Niaz: As far as I know you hold several patents. Please tell us about your patents?

Catherine: Most of these are in the area of manipulation or vision on the da Vinci System. You’ll notice that few, if any, of those patents list me as the sole inventor. Invention tends to come when you are solving a new problem with a team, and have the opportunity to try novel solutions. The best ideas are also often hybrids of many people building upon and improving each other’s ideas as you solve a problem together. Patents certainly serve a purpose in that they give you a period of time in which to use an idea before a competitor can legally copy it, but it is the teamwork and problem solving aspect of it that I enjoy the most.

Niaz: What is your favorite part about working at Intuitive Surgical?

Catherine: Getting to remain on the steep part of the learning curve – medicine and technology are changing so rapidly, that keeping up with what is going on is a constant process – one that I enjoy very much.

Niaz: As Vice President of Medical Research, what do you do on a daily basis? What is a normal day like for you?

Catherine: I’m not sure if I really have a normal day. Some days are lab days when we are in the research operating room developing new procedures or testing out prototypes of new instruments. Other days involve traveling around and both speaking about our technology and learning about new technologies from their inventors. And, some days involve trying to look out into the future to see what changes are happening in medicine so that our next products fit the new needs that are arising.

Niaz: What other kinds of projects or initiatives have you been involved in?

Catherine: I started playing the cello recently, and through building our house and blogging about it, I have been active in the conversation about green building and native plant gardening. Recently, I have also started working with GAVI, the vaccine alliance, on technologies for tracking vaccines in developing countries.

Niaz: You wanted to save the world, or at least a piece of it. But you just weren’t sure how to go about it. And now in 2014, we can see your profound body of works that have helped to change the world of robotic surgery and sustainable technologies. I know there are still a lot more to come. What would be your advice for the ones who want to follow your footsteps and change the world to make it a better place to live in?

Catherine: Focus on the problems that matter to you, if it matters to you, it probably matters to other people too. People make the mistake of focusing on what they think other people want, and then their hearts are never really in it. Without passion you won’t have the drive to do all the really hard work that comes with trying to make a difference. People are very impatient for success now, but it will never come unless they take the time to become deeply educated and skilled in the areas needed to be able to make a contribution.

Niaz: Any last comment?

Catherine: The technologies that will probably shape our future careers are in labs somewhere. I expect I will reinvent myself several more times as those technologies come out of the lab and start changing our world.

Niaz: Thanks a lot for joining and sharing us your great ideas, insights and knowledge. We are wishing you very good luck for all of your upcoming great endeavors.

Catherine: Thank you for putting this program together

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Further Reading:

1. Andrew Hessel on Biotechnology, Genetic Engineering and Future of Life Science

2. Aubrey de Grey on Aging and Overcoming Death

3. Irving Wladawsky-Berger on Evolution of Technology and Innovation

4. Gerd Leonhard on Big Data and the Future of Media, Marketing and Technology

5. Viktor Mayer-Schönberger on Big Data Revolution

6. James Kobielus on Big Data, Cognitive Computing and Future of Product

7. danah boyd on Future of Technology and Social Media

8. James Allworth on Disruptive Innovation

9. Brian Keegan on Big Data

10. Ely Kahn on Big Data, Startup and Entrepreneurship

Aubrey de Grey: Aging and Overcoming Death

Editor’s Note: Dr. Aubrey de Grey is a true maverick. He challenges the most basic assumption underlying the human condition – that aging is inevitable. He argues instead that aging is a disease – one that can be cured if it’s approached as “an engineering problem.”

He is a biomedical gerontologist based in Cambridge, UK, and is the Chief Science Officer of SENS Foundation, a non-profit charity dedicated to combating the aging process. He is also Editor-in-Chief of Rejuvenation Research, the world’s only peer-reviewed journal focused on intervention in aging. His research interest encompass the causes of all cellular side-effects of metabolism (“damage”) that constitute mammalian aging and the design of interventions to repair and /or obviate that damage. You can read his full bio from here here here and here.

eTalk’s Niaz Uddin has interviewed Aubrey de Grey recently to gain insights about his ideas, research and works in the field of aging which is given below.

Niaz: Dear Aubrey, I know you are a very busy man and I really appreciate you for taking time out of your schedule to join me. We are very thrilled and honored to have you at eTalks.

Aubrey: My pleasure.

Niaz: At the beginning of our interview, could you please say a few words about your background and the positions that you hold today?

Aubrey: I was initially trained as a computer scientist, but I switched to the biology of aging at around 30 when I discovered, to my astonishment, that very few researchers were really working on doing anything about aging. Currently I’m the Chief Science Officer of SENS Research Foundation, a California-based biomedical research charity focused on developing the strategy for defeating aging that I proposed back in 2000.

Niaz: That’s really interesting. What did first attract you to the idea of physical immortality?

Aubrey: First, let’s be totally clear that I don’t work on “immortality”, or any variations on that theme. I work on health: I want to let people stay fully healthy, i.e. functioning both physically and mentally as well as a young adult, at any age. Once this is achieved, it is very likely that there will be a dramatic side-benefit in terms of how long people live – but that’s what it is, a side-benefit. I do not work on longevity for longevity’s sake. So, to answer what your question should have been: what attracted me to the crusade to bring aging under medical control was simply that it was obviously humanity’s worst problem but hardly anyone was working on it.

Niaz: What’s so wrong with getting old? Is getting old the biggest health crisis facing the world?

Aubrey: The way you phrase the question incorporates most of the answer. Most people have a totally distorted idea of what aging is: they think of it as distinct from the diseases of old age, and as something natural and inevitable, like the passage of time. So “getting old” is used pretty much interchangeably as either getting chronologically old or getting frail. WTF?! We don’t ask what’s so wrong with getting Alzheimer’s, so it makes no sense to ask what’s so wrong with going downhill in all ways.

Niaz: You’re a true maverick and you challenge the most basic assumption underlying the human condition — that aging is inevitable. You argue instead that aging is a disease – one that can be cured if it’s approached as “an engineering problem.” Before we focus on your efforts to understand the aging process, perhaps we should first say a few words about aging itself. Why do organisms age, and die?

Aubrey: Aging is far less mysterious than most people assume. In its essence, aging of a living organism is no different than aging of a simple, man-made machine – which should be no surprise, since after all the body is a machine (whatever one’s view may be as regards any non-physical elements that combine with the body to form the human being). Thus, it’s totally reasonable – I would say obvious, but apparently it isn’t obvious to everyone – to look at how we already succeed in extending the healthy longevity of cars or aeroplanes waaay beyond how long they were designed to last, and apply the same principles to human aging. And those principles come down, in a nutshell to just one idea: preventative maintenance, i.e. repairing pre-symptomatic damage before symptoms emerge.

Niaz: So does the process of aging serve some evolutionary purpose — and if it does, will we run into trouble if we attempt to counteract it?

Aubrey: It does not. From the 1880s or so until the 1950s it was thought that aging helped species to be more nimble in responding evolutionarily to changing environments, but then Medawar pointed out that mortality from causes that aren’t related to age is so high in the wild that there are too few frail individuals to drive natural selection for aging even if in principle it would be a good thing for the species. Medawar’s observation was somewhat over simplistic, but today almost all gerontologists agree that his basic idea was correct and that there are no “genes for aging”.

Niaz: You are the Chief Science Officer of the SENS Foundation. What that acronym stands for and what the organization does? 

Aubrey: Strategies for Engineered Negligible Senescence, but I know that’s a bit of a mouthful. We do biomedical research to develop regenerative medicine against aging, i.e rejuvenation biotechnology that will restore people’s physical and mental function (and appearance, yes!) to that of a young adult.

Niaz: What’s been the most striking piece of data to support your hypotheses?

Aubrey: That’s not really the right question: I don’t have a “hypothesis”. What I have is a technological plan – a proposal for how to manipulate an aspect of nature – whereas hypotheses are conjectures about how nature works in the absence of manipulation. The reason I need to make this ostensibly nit-picking distinction is that pioneering technology does not proceed by the accumulation of data: rather, it consists of a leap of faith that putting established technologies together will deliver more than the sum of the parts. So we (and others) have certainly been making great progress in developing the component technologies that will in due course combine to defeat aging, but calling those advances “support for a hypothesis” is a misuse of terms.

Niaz: As you know, now we are living in an exciting era of bioinformatics and big data. What do you think about the role of bioinformatics and big data in this field?

Aubrey: The relevance of big data to biomedical gerontology is pretty much the same as throughout biology. It speeds up a huge variety of bench experiments, but it doesn’t derive many big ideas itself.

Niaz: Some people regard aging research, and efforts to extend lifespan, with suspicion. Why do you think that is? What is your response to those concerns?

Aubrey: It’s embodied in your question: people who recoil at this work do so because they regard “aging research” and “efforts to extend lifespan” as synonymous, when in fact “aging research” and “efforts to eliminate age-related disease and disability” are synonymous. The tragedy is that this misconception is so entrenched: even though gerontoogists have been correcting this error since decades before I came along, but no one wants to hear it, probably mainly because they don’t want to get their hopes up. I think this is finally changing now, but I’m not slowin down my advocacy efforts.

Niaz: You regard cancer as the greatest potential threat to your longevity program, but couldn’t mutant viruses represent an even greater threat?

Aubrey: Viruses are a huge issue, but they are small (they don’t have many genes), whereas cancer has the entire human genome at its mutational disposal. Pandemics are a problem mainly because we aren’t putting enough money into vaccine development: if we can just get our priorities right, the chances of any pandemic really taking off are infinitesimal.

Niaz: What are the other key problems in aging research?

Aubrey: Well, basically most non-SENS research revolves around identifying simple interventions (drugs, genes, diet) that can in some harmonious unitary way slow aging down. I support such research, because it may in many cases make a dent in aging far sooner than SENS will – but its impact will be far less than what SENS will do once it exists. As such, the way to save the most lives and alleviate the most suffering is to pursue both approaches.

Niaz: One of the important consequences of successful SENS research is that we will no longer lose creative, inventive individuals and their priceless gifts to humanity. It will really be exciting. You have assigned $13 million dollars out if $16.5 million dollars that you inherited from your mom to SENS. In addition, you have dedicated your life, all your time and money to this mission. Do you think you’re going to be successful as well as going to find out the ways to overcome death? What is the timeframe?

Aubrey: As a researcher, I intrinsically accept that I don’t know whether my work will succeed, but I am sufficiently motivated by the knowledge that it MAY succeed. I don’t think of myself as a betting man, but in that sense I suppose I am. As for timeframes, I think there is a 50% (at least) chance that this research will get us to what I’ve called “longevity escape velocity” within 20-25 years.

Niaz: WOW! That’s going to be incredible. Can the planet cope with people living so long?

Aubrey: People are incredibly bad at understanding the influences of the trajrctory of global population and how it would be altered by the defeat of aging, which is why we are funding a very prestigious group in Denver to analyse it authoritatively. The short answer is yes, we believe that the planet can certainly cope, partly because the currently-observed falling fertility rates and rising age at childbirth will continue, but also becaue new technologies such as renewable energy and nuclear fusion will greatly increase the planet’s carrying capacity.

Niaz: Google’s CEO, Larry Page, said: “Illness and aging affect all our families. With some longer term, moonshot thinking around healthcare and biotechnology, I believe we can improve millions of lives.” And very recently Google has announced a new company called Calico that will focus on health and well-being, in particular the challenge of aging and associated diseases.  What do you think about this move by Google?

Aubrey: It’s the single best piece of news in all the time I’ve been working in this field. Even though Calico is taking its time to determine its research priorities, I’m very confident that it will make huge contributions to hastening the defeat of aging.

Niaz: Now, as the editor of the journal of rejuvenation, obviously you have a lot of information coming across your desk all the time. I was wondering is there any particular research that excites you at the moment?

Aubrey: I really don’t want to single anything out. SENS is a divide-and-conquer strategy, and all its strands are moving forward very promisingly.

Niaz: You are exceptionally well connected with other scientists. I have seen you at TEDMED 2012 Conference. About how many scientific conferences do you attend each year? What is your main means of becoming acquainted with other scientists?

Aubrey: I give about 50 talks a year, at conferences, universities and elsewhere. I meet scientists there, of course, but also by contacts based on reading publications. In that regard I’m no different than any other scientist.

Niaz: What are your goals for the next decade?

Aubrey: To become obsolete. My goal is that by 2020 or so there will be people involved in this mission who are much better than me at all the tasks I’m good at and that currently the mission relies on me to perform.

Niaz: Is there anything else you would like for readers of eTalks to know about your work?

Aubrey: The main thing I want to communicate is that shortage of funding is delaying the defeat of aging by many years. My current estimate is that we could be going about three times faster if funding were not limiting – and the tragedy is that even a ten-fold increase, to something like $100m per year (way under 1% of the NIH’s butget), would pretty much eliminate that slowdown. We have a solid plan, and we have the world’s best researchers waiting and eager to get on and implement. All we need is the resources to let them get on with it.

Niaz: Dear Aubrey, thanks a lot for giving us time and sharing us your invaluable ides. We are wishing you very good luck for your tremendous success. Please take very good care of yourself.

Aubrey: My pleasure. Many thanks for the invitation.

Ending Note: It’s been more than a decade since Dr. Aubrey de Grey has established the principles behind SENS. You can visit sens.org and look at the summary of the principles over there. Also, of course, Dr. Aubrey recommends you his book “Ending Aging” which covers the strategy in lots of detail.

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Further Reading:

1. Viktor Mayer-Schönberger on Big Data Revolution

2. Gerd Leonhard on Big Data and the Future of Media, Marketing and Technology

3. Ely Kahn on Big Data, Startup and Entrepreneurship

4. Brian Keegan on Big Data

5. danah boyd on Future of Technology and Social Media

6. Irving Wladawsky-Berger on Evolution of Technology and Innovation

7. Horace Dediu on Asymco, Apple and Future of Computing

8. James Allworth on Disruptive Innovation

9. James Kobielus on Big Data, Cognitive Computing and Future of Product

Joseph P. Newhouse: Health Economics

Editor’s Note: Dr. Joseph P. Newhouse is the John D. MacArthur Professor of Health Policy and Management at Harvard University, Director of the Division of Health Policy Research and Education, Chair of the Committee on Higher Degrees in Health Policy, and Director of the Interfaculty Initiative in Health Policy.  He is a member of the faculties of the John F. Kennedy School of Government, the Harvard Medical School, the Harvard School of Public Health, and the Faculty of Arts and Sciences, as well as a Faculty Research Associate of the National Bureau of Economic Research.

You can read his full bio from here, here and here.

eTalk’s Niaz Uddin has interviewed Joseph P. Newhouse recently to gain insights about his ideas, research and works in the field of health economics which is given below.

Niaz: Dear Joseph, thank you so much for joining us. We are very honored and delighted to have you at eTalks.

Joseph: It’s my pleasure to join with you.

Niaz: You received B.A. and Ph.D. degrees in Economics from Harvard University. Following your Bachelors degree, you were a Fulbright Scholar in Germany.  You are John D. MacArthur Professor of Health Policy and Management at Harvard University, Director of the Division of Health Policy Research and Education, Chair of the Committee on Higher Degrees in Health Policy and Director of the Inter-faculty Initiative in Health Policy.  At the beginning of our interview can you please tell us about your educational journey and the transformation of your career from Economics to Healthcare?

Joseph: I have always thought of myself as an economist who worked in the applied area of health and medical care.  After I finished graduate school I joined the RAND Economics Department, intending to spend about half my time working on projects related to health and the other half of my time in other applied areas of economics.  In the domain of health I was interested in the demand for medical care and early on designed what became known as the RAND Health Insurance Experiment.  That projected required my full time – really more than full time – attention for 15 years, by which time I had given up any notion that I would work on topics not related to health and medical care.

Niaz: You are one of the nation’s top health economists. What do you think about health economics?

Joseph: I think health economics has two main streams of work.  One relates to medical care, with the seminal paper being Kenneth Arrow’s 1963 American Economic Review paper, Uncertainty and the Welfare Economics of Medical Care.”  This stream focuses on issues that arise because the market for medical goods and services differs in so many ways from the model of a perfectly competitive market in introductory economics textbooks.  The second relates to health as opposed to medical care, with the seminal work being Michael Grossman’s 1972 Journal of Political Economy paper, On the Concept of Health Capital and the Demand for Health” and his earlier National Bureau of Economic Research Monograph, “The Demand for Health.”  This line of work focuses on the actions of individuals that affect their health, and sometimes the health of others as well, including not only seeking medical care but also investing in education and engaging in various behaviors that are either beneficial or detrimental to health.

Niaz: What are the nucleus aspects of health economics that every policy maker should keep in mind?

Joseph: In answering this I take the perspective of a middle or high income country; the issues in low income countries differ somewhat.  The issue at the front of mind of most policy makers I interact with, as well as most citizens, is the cost of medical care.  In almost every country spending on medical care has risen faster than income, meaning it takes an ever larger share of tax revenue and often of households’ after tax income as well.  There are, of course, a huge number of suggestions and approaches coming from health economics to address the cost of care, but in the interest of being succinct, I will just mention two, both of which relate to the distinction between a high level of cost and a high growth rate of cost.

Every health care system has its share of inefficiencies; not surprisingly, most solutions proposed for dealing with health costs are directed at these inefficiencies.  One example is reducing paper work.  Although it is laudable to reduce inefficiency, success means one will have achieved a once-and-for-all reduction in cost, which will not necessarily reduce the steady state growth rate of cost.  In other words, once the inefficiency is eliminated, those savings have been achieved and costs will start to rise again unless a new action is taken.  Yet in the long run it is the steady state rate of growth that is the larger problem.  In other words, by all means minimize inefficiencies, but ultimately policy makers need a strategy for dealing with the growth rate.  Peter Orszag, when he was the director of the US Congressional Budget Office, called such a strategy this bending the curve.

The second observation relates to policies that address cost.  The growth in health care cost stems partly from the growth in income and partly from new and improved methods for treating patients of all sorts such as new drugs, new medical procedures, new medical devices, new imaging, and new diagnostic tests.  Growth in income and growth in knowledge interact; the developers of the new therapies expected to find a market for them, or they would not have proceeded to develop them.  Efforts to reduce the growth rate of cost will almost certainly slow development, but need to be done in a way that considers the benefits that may be foregone by adopting the new policy.  There are many diseases for which current therapy is not very effective, for example, many cancers as well as Alzheimers and other neurodegenerative diseases.  It would be worth giving up quite a lot to have effective cures for these diseases.  I hear too many discussions where it sounds as if the only objective is to reduce cost or the growth rate of cost rather than reduce or eliminate those activities that do not provide sufficient benefit.

Niaz: As you know, millions of people are now living under poverty line. They can’t afford to have food every day. Health care is mostly a day dream for them. After living hand to mouth they depart. And it has been happening decades after decades. What are your suggestions to save those people to live a healthy life and to contribute for this mother earth?

Joseph: My expertise pertains to higher income countries, but economic growth has pulled tens of millions out of poverty in China and India, and many low income countries have started to grow at good rates.  Such growth not only means higher household incomes but also enables public investment in infrastructure that can improve health.  That plus good governance are undoubtedly important in helping these people.

Niaz: Why private Medicare plans don’t cost less?

Joseph: Private Medicare plans are called Medicare Advantage plans.  They generally provide those who join them rather than joining traditional Medicare lower premiums, lower cost sharing, and/or additional covered services, but this is in part because of higher reimbursement.  My own view is that the larger benefit of well run plans, however, is better medical management of many chronic diseases such as diabetes. (I should note that I am a director of, and own equity in, Aetna, which sells Medicare Advantage plans.)

Niaz: We are living in the age of superb technological innovation. Most developed countries are taking optimum advantage of technological innovation for better health care. What are your ideas for under developed, developing and poor countries to take the advantage of technological innovation to build a better health care?

Joseph: Again, my expertise is around higher income countries, but I think an innovation with large promise for low income countries is mobile telephony because medical advice can be given over the phone to lower level personnel when transportation to physicians with more training is not feasible.

Niaz: Different countries have different health care policies. According to you, what should be the most priority for a country in setting health care policy?

Joseph: Each country has its own values, traditions, and health care institutions which quite properly shape its policy. For that reason I doubt that there is a general answer to this question.  But aspects of life styles in many countries are inimical to health.  For example, obesity rates have increased rapidly in many countries, so much so that some demographers predict life expectancy will fall.  Any use of tobacco is damaging to health, and its use varies substantially among countries.  Trying to promote a healthy life style plus insurance coverage to protect households from being devastated financially by illness are priorities that seem applicable to a wide range of countries.

Niaz: What will be the potential challenges/roadblocks in the way of implementing those top priorities? How can countries achieve those priorities?

Joseph: Lifestyles are difficult to change, but we know that taxes can change use of goods such as tobacco.  Changing social norms also help; restricting the use of tobacco in public places, for example, has contributed to an overall fall in use.    Achieving universal coverage is largely a political issue, although there are certainly technical issues.

Niaz: Can you please briefly tell us about your book ‘Free for All: Lessons from the RAND Health Insurance Experiment’? 

Joseph: The booksummarized the results of perhaps the largest health services research project ever done.  The Experiment was a randomized trial that varied the level of initial cost sharing for medical services; some families received all care at no cost to them, others had (approximately) a large deductible, and still others were intermediate.  The cost sharing was scaled down for lower income households.

The use of services clearly responded to what patients had to pay out of pocket; use was roughly 30 percent higher if patients didn’t have to pay that if they faced a large deductible.   For the average person we found minimal deleterious effects of cost sharing on health outcomes, but low income hypertensives had their blood pressure better controlled if care was free.  In addition, some families were randomized to a Health Maintenance Organization, where care was free if it was sought at the Organization.  Those families made markedly less use of the hospital than families in the fee-for-service system and we detected no adverse effects on their health.

Niaz: Our readers will also love to know about ‘Pricing the Priceless: A Health Care Conundrum’. Can you also please tell us about it?

Joseph: This book is an elaboration of the Walras-Pareto Lectures given in Lausanne in 1997.  I tried to summarize the many years I had spent on Commissions that advised the American Congress on setting reimbursement in Medicare.  I went through several examples of how easy it is to misprice in administered price systems and then went on to consider mixed systems of reimbursement, part fee-for-service and part capitation.

Niaz: You have been doing all exciting works in your whole career. You have achieved a wide variety of prestigious awards. You have been leading great organizations. What does excite you always to do the next big thing?

Joseph: To learn what is not known, to teach the next generation, and to learn from my colleagues.

Niaz: I have learned that you love to spend your spare time with your grandchildren and playing golf? Do you actually get spare time? 

Joseph: Most definitely.

Niaz: Can you please share us about the secrets of your sustainable remarkable career? 

Joseph: Thank you for the compliment.  I have tried to work on problems that I felt were important, and I have been blessed to have many wonderful colleagues who have helped me enormously.

Niaz: What is your advice to people who want to follow your footsteps?

Joseph: Choose important problems to work on that motivate you and are tractable, and surround yourself with persons whose skills complement yours.

Niaz: Any last comment?

Joseph: Thank you for giving me this opportunity.

Niaz: Finally, we are grateful to you to have your precious time. Thanks again to share us your invaluable ideas, knowledge and experience. We wish you luck for your good health and impressive works.

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Further Reading:

1. Peter Klein on Entrepreneurship, Economics and Education

2. Derek Sivers on  Entrepreneurship, CD Baby and Wood Egg

3. F. M. Scherer on Industrial Economy, Digital Economy and Innovation

4. Diego Comin on Entrepreneurship, Technology and Global Economic Development

5. Stephen Walt on Global Development

6. Juliana Rotich on Social Entrepreneurial Innovation

7. Joseph Nye on Global Politics