Commencement address given at the University of California Berkeley, School of Public Health, Berkeley, California, May 13, 2024
The Future of Healthcare
By Gerald Chan
From a training in science when I was young, my career meandered to my eventually becoming a venture capitalist. As the word venture implies, what I do is to take risks to create something that doesn’t yet exist. In particular, what I do is to make new drugs to serve unmet medical needs.
In the last three years, the companies I had helped build had three drugs approved by the FDA. One is priced at two hundred thousand dollars per patient per year. The second drug is for a rare disease and is priced at four hundred fifty thousand dollars per patient per year. The third drug addresses the leading cause of blindness in the elderly which afflicts millions of people. That drug is priced at twenty thousand dollars per eye per year. Unlike infectious diseases where a course of antibiotic or antiviral cures the patient, disease-modifying drugs for chronic conditions require the patients’ lifelong usage. The financial impact of such drugs is all too obvious. When the sales of these three drugs are fully rolled out, they will add billions of dollars each year to the financial burden of healthcare systems in this country.
What have I done? At the level of individual patients, there are now drugs for their diseases whereas previously there were none. This is good news for those patients. But at the system level, these successes have added a huge burden to healthcare expenditure. Looking at healthcare systems around the world, few are not already buckling under the weight of their financial burden. As a result, patients are obliged to help shoulder this financial burden in three ways — hefty co-pays, onerous prior authorization before receiving care, and long waiting time for appointments and procedures. This is why having health insurance coverage in America does not necessarily mean that there are no impediments to getting care.
This is where public health comes in. The years I spent in a school of public health as a graduate student taught me to look at the world through a public health lens. Howard Hiatt, my dean at the time, said it best, “Public health is the conscience of medicine.”
It was this public health conscience that led to a pivot in my career aspirations. Instead of aspiring to make ever more expensive drugs, can I contribute to making healthcare better and cheaper? Can I design new models of care delivery such that there is no barrier for anyone to access healthcare? Can technology help in care delivery such that each healthcare professional can better take care of more people without being put at risk of burnout? The gravity of this burnout problem feels surprisingly first-hand to me because along with undergraduates coming to me seeking advice on how to get into medical school, mid-career physicians come to me with equal determination to seek advice on how to get out from practicing medicine.
The adequacy of our future healthcare workforce is far from secure. Witness the residents’ unionization drive sweeping across the country, and the attending physicians are following right behind. It will be a matter of time before we will see doctors strike like what took place in UK, Germany and Korea in recent months. Everywhere around the country, large hospitals have hundreds of vacancies in their nursing staff that they cannot fill. Staff shortage and staff burnout feed on each other in a vicious cycle. Among the medical specialties, the shortage of primary care physicians is particularly dire. As of six months ago, the largest health system in the Boston area has shut its doors to any new primary care patients. If you had just moved into town and are looking for a primary care doctor, tough luck.
This looming crisis of healthcare workforce will only get worse over time. Declining birth rates coupled with people living longer mean that there will be less young people to take care of the senior folks. If the solution to the lack of workers in manufacturing is automation, why wouldn’t we use technology to increase productivity in healthcare?
Whether we look at cost, access, or the workforce, it is evident that our healthcare system is broken, but change in healthcare is exceedingly difficult because medicine is inherently conservative. When patients’ lives are at stake, people have extraordinary capacity to tolerate poor but known outcomes rather than taking risk to innovate for better outcomes. If my career in venture had taught me one thing, it is that there is no innovation without risk taking. Every innovator is a risk taker. I wish that our education system encourages people to take risks as much as it trains people to conform.
I want to share with you the story of two young men that I have had the pleasure of working with in the last three years. Ivan and Will, both first generation immigrants in Britain — one from Africa and the other from China — were medical students in London. By their second year in medical school, they saw the dysfunction of the National Health Service (NHS) and the impossibility of the status quo to meet the healthcare needs of society. They saw a system so conservative and so bureaucratic that even in the face of disastrously poor performance, there was no appetite for change. Ivan and Will felt that throughout medical school, they were being beaten into conformity. It became increasingly apparent to them that they had to choose either to stay in the system and be stifled or venture out of the system to innovate.
One of them took a year off to study data science. By the time they graduated from medical school, they had made up their mind not to go into internship and residency. Instead, they founded a company in an attempt to radically change how patients with chronic conditions are cared for. Those of you who are from immigrant families would appreciate this. A young person had worked hard his whole life to get to medical school. The hopes, the pride, and the financial security of the whole family rest on his being a doctor. And now, on the cusp of becoming a doctor, he walks away from a career in medicine. This is rather radical, and certainly very risky.
Ivan and Will started their company by working on hypertension, a silent killer that affects 30% of the world’s population. Using data and what may be considered rather crude artificial intelligence, they went into NHS health records and found thousands of patients whose hypertension was not known to the system, much less being treated. Rather than requiring the patient to come in between 9 to 5 to see a doctor, all communications were conducted asynchronously by the patient texting with a care giver who is a healthcare professional not unlike a nurse practitioner in this country.
We now use texting to conduct so many of the affairs of daily life. Why wouldn’t we use it for delivering healthcare? Our antiquated healthcare system was built around requiring the patient to come into the hospital or clinic to see a doctor. Few people appreciate how much impediment this requirement can be to accessing healthcare. A friend of mine who worked in the hospital in Boston’s Chinatown told me that the breast cancer patients who were Chinese restaurant workers inevitably presented with late-stage disease. Why? Surely, they knew from self-examination that there was a lump in the breast. The real reason was that they could not take time off from work to see a doctor. These are people whose jobs make no provision for time off, or people with no cushion between their pay and their cost of living. If they could not afford healthcare, it is because they cannot afford to forgo half a day’s pay in order to go see a doctor.
Today, a mere two years after Ivan and Will launched their service with several NHS trusts, they are caring for 180,000 hypertensive patients across the UK. That number is on track to be half a million in a year. Through text communication, these patients are coached and monitored for their medication compliance. The result is that 70% of them have their blood pressure brought under control in four weeks. These results stand in contrast with the usual NHS practice which takes 2 to 3 months with 3 to 4 doctor’s appointments for a hypertensive patient to get his blood pressure under control. The reduction in healthcare cost here is measured not in percentages, but in how many folds, not to say the downstream savings because these patients have now lowered their risks for having a stroke later in life, or a heart attack, or an aneurism, or kidney problems, eye problems, heart failure or dementia. The work of Ivan and Will has the potential of radically changing the hypertension landscape of the entire British population.
There is no reason why this model of healthcare delivery cannot be applied to managing other chronic conditions such as dyslipidemia, diabetes, asthma, chronic obstructive pulmonary disease, and depression. If we can greatly improve outcome and drastically lower cost by innovative models of care delivery, we are now truly impacting population health.
I tell the story of Ivan and Will to illustrate that change is possible even with a bureaucracy as resistant to change as the NHS. With nearly two million employees, the NHS is a lumbering giant, the product of seven decades of patchwork protocols, band-aid solutions, entrenched practices, civil service mentality, interference and window dressing by politicians, and quixotic policies designed by well-meaning policy wonks. It is a system incapable of getting out of its own way. Even in such a system, two young men have found a way to introduce change and delivered massive impact.
I also want to point out that in their caring for thousands of patients that the public system had failed, Ivan and Will are doing so as a private sector company with for-profit venture backing. In a clever way, their work is both inside and outside the NHS. It is a fine example of how the public sector and the private sector can work together effectively to achieve better health outcomes for society.
People on the political right vilify government as the problem and not the solution. People on the political left denounce the private sector as categorically evil. Both are partly right, and both are hugely wrong. One thing for sure is that such polarization does not serve the best interest of the public good. Any suggestion that a wholly nationalized or a wholly privatized healthcare system will fix all the problems ailing healthcare is nothing but a pipe dream.
In the long career ahead of you, don’t be surprised that there will be times when your aspirations for improving the public’s health will be best served by working in the private sector. Alternatively, you may come to a juncture in your career that you feel the calling to go into public service. Both are good. Indeed, it is desirable for people to go back and forth between the private and the public sectors in the course of their careers. Such crisscrossing will both make their career more rewarding and their work more effective.
But wherever you work, even in institutions as difficult to change as government, it is possible to innovate. Innovation is a mindset, it is a mental habit, it is an intolerance for poor outcomes, it is an eye to see deficiencies as a prelude to something better, it is taking risk to challenge the status quo, it is thinking the unthinkable to create alternatives. In each of our own way, we can be a change agent that makes things better for our fellow men, for our institutions and for our communities.
I want to close by congratulating all the graduates for reaching today’s milestone in your educational journey. Here at UC Berkeley, you have studied in one of the nation’s premier public health schools. Your training has equipped you to tackle the world’s health challenges. Now, with this excellent training you have received, with your youthful energy, and with the blessing of your loved ones, go forth, spread your wings, embrace new challenges, take some risks, and together, we will make the world a healthier place.