On September 20, 2017, The Washington Post brought together doctors, researchers, scientists, medical technology pioneers and business leaders who are pushing boundaries in the health sector and transforming the way we live. They discussed advances in genetics, immunology and technology that are poised to transform human health and make treatments more affordable, accessible — and ultimately — more effective. (Kristoffer Tripplaar)

This transcript has been edited for readability.

On the Cutting Edge: Precision Medicine

Bernstein:        Hi, everyone.  I’m Lenny Bernstein, the health and medicine reporter for The Post.  They just told you that.  I’m joined here on stage with Dr. Francis Collins, director of the National Institute of Health and we are going to talk about the efforts at NIH to accelerate scientific research, particularly advancements in the area of precision medicine.  For those of you in the audience and for people watching online, you can send us your questions on Twitter using the hashtag #Transformers or you can comment on our Facebook live stream.  Dr. Collins, thanks for being with us.

Collins:            Thanks, Lenny.  It’s great to be here as part of Transformers.  It’s quite an afternoon you’ve got lined up here.

Bernstein:        So just about a year ago, I think you and I were here on the same stage and we were talking about precision medicine.

Collins:            What about that?

Bernstein:        NIH hasn’t gone away.  [LAUGHTER] NIH has a big program underway called “All of Us”.

Collins:            Yes.

Bernstein:        Could you update us and tell us where that stands?

Collins:            I’d be happy to.  So this is one of the boldest undertakings that NIH has ever tried to design and implement.  When it’s fully fleshed out and fully enrolled, it will include one million Americans as full participants in a long-term study of health and disease.  All of those individuals will be asked to sign up to make their electronic health records available in a secure system, to wear wearable sensors, like Fitbits and other things to keep track of what’s happening to their body’s performance, to fill out a lot of questionnaires about their personal health, and to give a blood sample for a variety of laboratory measures, including a complete DNA sequence of their genomes.  And to be participants, not just subjects.  I think we should probably not use that word anymore in medical research because it has that unfortunate connotation of something’s being done to you.

These are going to participants; partners in an effort.  They will get a lot of information back about themselves that may be quite interesting and somewhat useful in terms of their own medical care and they will be part of this amazing national adventure that is going to shed probably more light on how to keep people healthy and how to manage chronic illness than almost anything we’ve ever done.  At the moment, this is in what we call the “beta test phase.”  There are 10 health provider organizations across the country that are involved in this and are funded to take part in it.

Currently, this year, we’re spending about $300 million on getting this all up and going and that’s a program that’s going to go on for many years.  They then reach out to their participants and invite them to join up.  A very careful consent process is involved in that.  But we also want to make this available to anybody in the United States, so there will be a direct volunteer opportunity for people to sign up.  We’re also reaching out to community health centers.  We particularly want to enroll many people who traditionally have not been part of medical research.  In fact, we’d like more than half of the one million participants to be of that kind of underrepresented group, which is pretty bold.

Bernstein:        So these are racial and ethnic minorities?

Collins:            Racial and ethnic minorities, socioeconomic status.  People who might not necessarily be engaged in research.  Rural participants, who oftentimes don’t get touched by medical research opportunities.  All of that together, look at those various groups.  We want lots of those folks because we want to understand health disparities as well.

Bernstein:        Why has it been so difficult to recruit those folks?

Collins:            I think many times, it’s just a matter of logistics and that the major medical centers that do research don’t happen to be close by to where some of the people in the country live.  Frankly, some ethnic groups are suspicious of medical research, and maybe with good reason, considering some of the experiences that have happened in the past.  If you are doing a medical research program reaching out to African-Americans, almost always, you’ve got to talk about Tuskegee and what happened there and how are we going to be sure that that never, ever happens again?

I think because of this “All of Us” program; and that’s what it’s called: “All of Us”—aims to have as its team members the same diversity that it has in its participants that gives a certain credibility about what this project is all about.  So the beta is underway.  We’ve already enrolled a few thousand people.  We are kicking the tires.  We want to be sure that all of the pieces work.  There’s a biobank at the Mayo Clinic that’s prepared to take 32 million samples and store them in a carefully bar-coded way so you can find the one you are looking for.  There is a database plan and a security system that’s as best as the world can provide because we want to be sure that this kind of system is not subject to hacking, which could be very unfortunate and might cause a lot of people to wonder if they want to take part.

Eric Dishman, who is the director, was hired by me from Intel to run this and man, does he know how to run a program and we’ve got a lot of people lined up in these 93 organizations to try to be sure that everything is going in the right sequence.  But we want to launch when it’s ready and right and we don’t want to rush that if there are any concerns about whether the beta test is telling us we have some work to do.  So before we go into this national launch, which you’ll hear about in a big way when we get there—it will take a few more months.

Bernstein:        Can children participate?

Collins:            At the moment, we are not starting with children but we aim after the first year to start to enroll children.  It’s more complicated there in terms of consent and involvement of parents.  We have a working group right now that’s trying to be sure when we do that part that we do it right.  But it will probably take another year before it’s time to open up to kids.

Bernstein:        And just if you could shorthand for us, years down the road, the gathering of this data is expected to lead to what kind of payoff?  What’s the payoff?

Collins:            Well, bunches of things.  [LAUGHS] Let’s just name one.  So we know, for instance, that the way in which people are benefitted or not by drug treatments depends a fair amount upon their personal circumstances, especially their DNA and this is called pharmacogenomics.  FDA on its label, more than 100 drugs say that before the doctor gives this prescription, you might want to know your particular DNA result at this particular enzyme that maybe metabolizes that drug because it’s going to affect the dose that you ought to get.  But we’re not doing that and we’re not doing it not because the information is not there.  It’s just not practical.  If you go to your doc today and you have a condition that needs a drug prescription to written—maybe you need a statin.

Your DNA is not available and to actually get that test and get the result back and interpret it, it would take a long time.  These million people will have their DNA available.  It’s already been done.  It’s there in the record and so we could have very quickly a test of pharmacogenomics: does this actually improve outcomes for a long list of drugs where we think it should make for a better result because you get the right dose of the right drug for the right person at the right time.  As opposed to the one-size-fits-all approach.  That will be a fairly early benefit of all of us and as we watch people over the course of a few years develop signs of illness or maybe actual illness, we could look back because we’ll have data on those individuals and try to figure out what was the trigger and then use that information to help prevent that illness in other people.

This is going to be heavily focused on prevention but also on chronic illness.  Another thing we could do that I think all of the other research communities, both public and private, are really interested in; if you have a million people with all of this data and who are interested in research and are already consented to have people come back to them and invite them to take part in another trial—suppose you wanted to do a test of an artificial pancreas for diabetes and you want to reach out to people who would qualify for that.  In a study of a million people, there will be tens of thousands of those folks and they’d probably be pretty interested in hearing from you.  So this is going to elevate all of the ways we do clinical research by having this foundational framework.  And by the way—

Bernstein:        You eliminate your lead-up time?

Collins:            Yes, indeed.

Bernstein:        Because it can take years.

Collins:            That’s often what counts.  Many years.  And by the way, we call it a million.  If it’s more than a million, I’ll be even happier.  [LAUGHTER] It’s what we can afford.

Bernstein:        I want to switch us over to something that’s more current, that’s affecting us right now, the opioid epidemic.  NIH is about it dive into that in a big way.

Collins:            A big way.

Bernstein:        You’re starting a program with the pharmaceutical companies.  It has—you can correct me if I’m wrong here—three very ambitious goals.  You want to work on non-addictive medications for chronic pain.

Collins:            Yes.

Bernstein:        Better treatments for opioid addiction.

Collins:            Yes.

Bernstein:        Which in and of itself is a huge step, and improved antidotes.  Say the next generation of naloxone.  Can you give us an overview of what NIH is doing there?

Collins:            I’d be happy to.  We have, as one of our 27 institutes and centers is the National Institute of Drug Abuse.  Its director, Dr. Nora Volkow is one of the world’s experts in the neuroscience of what drug addiction is all about, and particularly opioids.  And this is something where one really needs to understand the diabolical way that this particular set of compounds rewires the brain in order to appreciate how those who become addicted really are in a circumstance where they can no more just by the free will, a decision, get free of the addiction, then you could get free of needing to eat or drink.  This has become an absolutely compelling drive that will cause people to do things that you can’t imagine is good judgment, but it is overwhelming in the need.

We also need to recognize, because I think some people who have not paid attention to this epidemic assume that this is people who just started on injectable heroin and 80% of the people who are currently addicted to opioids, many of which are not injectors, started with prescription drugs.  And it was the medical profession, I’m sorry to say, in the late 1990s that greatly began to increase the prescription of opioids because of a sense that as long as somebody actually was in pain, they couldn’t get addicted.  Well, we found out that’s absolutely wrong.

So we have a desperate need here.  What can NIH do?  You mentioned the three areas.  We do need better ways to treat people who have chronic, severe pain with drugs that are not going to end up putting them in this addicted state with the tens of thousands of deaths each year that we now see from overdoses.  And there are some pretty good ideas out there.  We’ve learned a lot about the neuroscience of pain.  And so there are other drug targets that haven’t yet been fully pursued and companies are interested in this.  So just on Monday, I was in Trenton with Governor Christie and the CEOs of 15 pharmaceutical companies and the FDA gathered around the table with the governor, who is the head of the president’s commission on the opioid use crisis, and basically making a commitment to work together to try to speed up the development of those non-addictive but potent pain medicines.

That if we really made this a high priority—maybe like we did for HIV-AIDS 20 years ago, we could come up with better therapeutics and I think we can.

Bernstein:        So is the idea to separate the addictive quality of the—

Collins:            Yes.

Bernstein:        Medication from the analgesic quality of that?

Collins:            That’s exactly right, Lenny, and that’s what we need.  Because right now, opioids are the most effective treatment for acute pain.  They really were, but they have this really terrible side effect of needing more and more and more and anybody who has been on these for more than about 10 days, is going to have trouble stepping away from them and far too many people don’t know that and end up caught in a difficult place.

We’re also working with the industry as part of this on coming up with better treatments for the two million Americans who are already addicted; two million people.  How many of those are in effective treatment programs right now?  It’s a very small percentage.  And part of the problem is the treatment programs that are currently available are pretty limited.  There’s methadone, which means you’ve got to show up at a clinic every day so you can take your pill or your liquid.  There is buprenorphine, which actually works pretty well, but we need more ways in which it could be distributed.  Maybe it could be a daily dose or a weekly dose even a six-month dose.  And there’s now naltrexone, which is sort of an antagonist against any kind of opioid, which works pretty well for people who are already completely clean to help them stay that way.

But we need more options and they are ways to do that actually in the short-term that we could work on with industry.

Bernstein:        Why are so few people getting those medications if they have been found to be effective?

Collins:            I think this has been an epidemic that has kind of sneaked up on us and the increase in numbers of addicted individuals and numbers of overdose deaths has just been breathtaking and the medical system was not very well prepared for that.  The medication-assisted treatment, MAT, which is what you really need to treat an addicted person and have a chance of it working, has not been available, even in many of the clinics that were advertising that they could help people.  I’m not sure that that has been a good thing.  The relapse rate has been horrendously high for many of those clinics.  So the data is just sort of becoming clear.

It is a good thing, though, that 21st Century Cures bill that the Congress passed has a billion dollars in it going out to the states to put more of those medication-assisted treatment clinics in place.  But there’s still a mismatch; a terrible mismatch between the supply and the availability and the need for people who are looking for those clinics to happen.  We have a ways to go.  Physicians, I think, have generally not wanted to get engaged in these kinds of treatments and we need the medical profession to stand up and say, “Hey, if we can write a prescription for opioid, you also ought to be willing to get involved in a treatment program for somebody who has gotten addicted.”

Bernstein:        Now, one thing we’ve had since I think the ‘70s, which is quite effective, thank goodness, is naloxone.

Collins:            Yes.

Bernstein:        But you feel that that could be improved upon?


Bernstein:        It’s actually the antidote for—

Collins:            Also called Narcan.  If you have an opioid overdose and you’ve stopped breathing, you better hope that somebody nearby in the next four minutes has Narcan, either as an injectable form, or better yet, as a nasal form.  The nasal form, by the way, it’s just a little mist.  It’s something we worked on, NIH, with a company to develop that.  It has now become available to many first responders.  It’s a lot cheaper than the injectable form, and it also is easier for non-medical people to administer.  You just stick it in their nose and give a squirt.

Bernstein:        And it’s really almost everywhere at this point.

Collins:            And it is.  The problem is with the introduction into the heroin supply of these synthetic opioids called fentanyl, and even worse, carfentanil.  They are so potent that we are hearing more and more stories of individuals who had an overdose, who got the naloxone antidote and who seemed to come around but then slipped back into a respiratory arrest because it wasn’t strong enough for that very, very powerful fentanyl overdose.  So we may need a stronger version of this with a longer duration of action.  And there are companies we’re working with that know how to do that and that’s one of those things also that could be done pretty quickly if we put our efforts together.

So this partnership, which is what we’re now trying to turn into a reality, is something which I think NIH can help with.  FDA is in there in a big way as well.  We’ve done partnerships for other things, like diabetes and Alzheimer’s disease and rheumatoid arthritis and Parkinson’s disease and cancer.  Those are all partnerships between NIH and industry.  Let’s see if we can do something like that for this unbelievable health crisis that we’re in the middle of.  More people died last year of opioid overdoses than died of HIV-AID at the peak of the epidemic in the U.S. in the late 1980s.  And yet, the attention going to this hasn’t been anything like what that was.

Bernstein:        You mentioned relapse and just briefly because we have one more thing we want to talk about—biologically, why do more than half of people who actually do get some form of treatment, some form of rehab, relapse and go back on opioids?

Collins:            It’s this problem of rewiring the brain which has happened when you’re addicted to opioids and it takes a long time to recover from that and to get back to the point where that utter compulsion to get that next dose of opioids is actually something you can manage to resist.  This is a very important issue.  It’s pretty clear that most of the programs that treat people for 28 days have a relapse rate that’s even higher than what you said.  Some of them—90% plus and we need to know exactly what those relapse rates are.  We don’t know, actually, for the individual what should be the duration of treatment before you can begin to taper and have that relapse not immediately come back around again.  That’s a critical question.

Bernstein:        So is there a biological or a neurological approach to improving those numbers?

Collins:            I think part of it, coming back to precision medicine is to recognize that we’re not all the same and this may be a process that requires longer treatment for some than others.  One of the things we’re working on with industry would be a biomarker; a way of assessing whether that individual is now at the point where they would not be at such a high risk for relapse without taking the chance of withdrawing the treatment and having that happen.  And there are some pretty good ideas about how to do that with imaging, for instance.  If you could look at the brain and actually see the wiring is different in an addict versus somebody who is not, then maybe you could watch that gradually revert back to normal and have a correlation there to tell you, “Okay, it’s probably safe now to begin to withdraw that medication-assisted treatment.”

Bernstein:        A little bit happier topic.  Every time the administration tries to cut your budget, Congress restores it.  Sometimes and maybe every time, if I’m remembering correctly, they add money to the request.  These folks want to have what you’re having so what’s the secret to getting your budget kept healthy by the U.S. Congress?

Collins:            Well, I think the real secret is that the value of biomedical research as an investment of the federal government is just incredibly compelling when you look at what this does for advancing the cause of human health and saving lives and you could look at that track record over decades and see how it has paid off.  Longevity going up, heart attack deaths going down.  Death from cancer also now going down, HIV-AIDS turned into a chronic illness instead of a certain death.  All of those things are very documented in terms of how a modest investment in medical research by the federal government has paid off in terms of human health.

It’s also paid off in terms of economics, which I think Congress pays a lot of attention to.  Every dollar that NIH puts into a grant returns $8.38 in terms of economic growth over the next eight years, counting the partnerships with industry that come as a result of that.  And there’s this argument also if you want to bend the healthcare cost curve for things like Alzheimer’s disease, which otherwise are going to break the bank of our economy, already approaching $300 billion a year.  That is something where you have to come up with a research plan that is going to give you a way to prevent or treat a disease like Alzheimer’s.  So if you really want to invest in that, NIH is the place.  Working with industry, but we do the basic part of it that is essential, that you want to put the investment in there.

And finally, there’s this issue of leadership in the world.  America has been the leader in biomedical research for the last 30 years, unquestioned.  That leadership’s being challenged by other countries and it’s good that they’re investing in science and China is particularly investing in science.  But do we really want to step off the stage when you can see what benefits have come to our country from being in that leadership role.  Don’t you think we ought to support that?  The Congress tends to pay attention to that too.  So I don’t have to make this case.  It makes itself and when it comes to those decisions about where taxpayers’ money ought to be put.  With the Congress representing them, medical research always comes out as a strongly supported, bipartisan, non-political homerun.

Bernstein:        Not only does Dr. Collins know everything about everything, but he stops precisely on the 0, 0, 0.  [LAUGHTER] Which is pretty amazing, considering.  I’ve interviewed a lot of people.  So that’s all the time we have today.  I would like to thank Dr. Collins for joining us, kicking off our conference, and I’m going to hand things off to my colleague, William Wan.

The New Frontier: Technology

Wan:                Great.  Good afternoon.  I’m William Wan, I’m a science correspondent at The Washington Post.  Our next discussion is going to focus on the convergence between medicine and emerging technologies.  So, joining me on the stage for the conversation, we have Dr. Anthony Atala.  He’s the director of the Wake Forest Institute for Regenerative Medicine, and Dr. Atala has been doing this groundbreaking work in the area of creating organs, manufacturing bones, tissue, various ways of doing that, including 3D printing, some very exciting work over the last decade.

And then also joining us, we have Dr. Daniel Kraft.  He’s the founding executive director and chair of the exponential medicine at Singularity University.  And Dr. Kraft’s program explores convergent, rapidly developing technologies and their potential in biomedicine and healthcare.  And then we have Dr. James Lu.  He is senior vice president of applied genomics, and cofounder of the Silicon Valley startup Helix.  Helix is sequencing customer’s DNA and matching them with genetic tests for hereditary diseases and other personalized tests and health-related products.

And last, we have Dr. Girish Putcha.  He’s chief medical officer at the health tech startup Freenome, which conducts research and accelerates accessible and non-invasive disease screenings to treat cancer and other diseases at earlier stages.  This is otherwise—I think some applications are called liquid biopsy, is that right?  Yeah.  And so, I just want to say thank you all for joining us.  So, I guess I’ll start with you, Dr. Atala.  I’m just curious, can you give us an idea of where things stand now?  We’ve been hearing about creating organs as a way of helping this enormous need for transplant organs.  Can you give us an idea of the lay of the land where things stand?

Atala:              Absolutely.  Thank you.  So, one of the challenges today is that there are just so many people who require an organ.  The number of patients who actually are on the wait list is actually—has gone up six times—six times in about a 25-year period.  And in that time period, the actual number of transplants has barely gone up.  And the challenge, of course, is that we need more organs, and that is because we’re living longer.  So, as we live longer, organs tend to fail, so this field of regenerative medicine really tries to achieve the creation of these tissues and organs, to try to replace some of these challenges, in terms of the shortage.

Wan:                Where are things headed?  So, a decade from now, what are we going to see possible, in your mind?

Atala:              Well, right now, we do have some tissues that have actually entered patient trials.  So, we do have a number of tissues now—flat structures such as skin, for example, which are the least complex; tubular structures have also entered clinical trials, such as blood vessels; hollow non-tubular organs like the bladder, vaginal organs.  These organs already now in patients, so patients are walking around with these engineered organs.

The big challenge, of course, are the solid organs; the heart, the lung, the kidney, and for those, I think that’s still going to be a while, in terms of getting these organs into patients, but there are now cell therapies, which are patient-specific.  Not stem cells, per say, but the patient’s own cells that can be grown and expanded, and then placed back into the body to augment functionality, and that’s actually also in clinical trials now.  So, I think the future in 10 years, you’re going to see a larger number of these tissues going into patients, and you’re going to see more patients hopefully benefitting from these technologies.

Wan:                Is there a holy grail in terms—a Moby Dick for you?  This is the organ that is the most complex.  If we have achieved this, we have achieved regenerative medicine.

Atala:              Well, in fact, the one organ which is in most need is the kidney.  So, if you look at the whole transplant wait list, 90% of the patients waiting for an organ are actually waiting for a kidney, at an immense cost to our healthcare system.  So, the average cost of having a patient on dialysis, for example, which is a system to make sure that your—these machines take care of the function the kidney would take care of, the average cost for a patient to be on these treatments is about $250,000 per year, per patient.  So, you can imagine these numbers adding up.

So, from a social standpoint, making patient’s lives better, improving their health, improving their daily quality of life, as well as having a savings to our healthcare system, the kidney would be the ideal one.

Wan:                Great.  And then Dr. Lu, I was going to ask you, you’re on the—kind of the frontiers.  Dr. Atala, he’s been going at this for decades, this regenerative medicine has been proceeding albeit kind of slowly.  You’re, it seems like, at the cusp of this new frontier of genomics, and I’m curious, what do you see as the possible applications in the immediate term, and then looking 20, 30 years, how do you see this playing out?

Lu:                   That’s a great question, and thank you for having me here, William, and thank you to The Washington Post.  I think what I’ll do is take a quick step back and explain a little bit of how we thought about the major trends we see in the healthcare system, and why we set up Helix the way we did.  And I think the first one was we saw increasing hunger for individuals and for patients to understand much more about their personal health.  And that we see that in the rapid adoption of digital health technologies.  Many people are now texting their physicians, they’re engaging in wearable technology, they’re using telemedicine, and that, frankly, these engaged patients are going to be a big part of their health over time, and that it’s important to understand it themselves, but also their genetic data over time.

I think the second thing we saw a lot of was that, frankly, the cost of sensors and gathering data about individuals is basically going to zero, although it seems like iPhones keep going up in price, sensor technology is going down to zero.  And genome will be fairly similar in that way, which is the cost to acquire genomes is going to go down, as well.  And so, the real opportunity is going to end up being at this intersection of all this disparate data sets that residing in all these applications around people.  And frankly, I think as of right now, the vast majority of, I would say, health data around individuals actually does not get generated in the health system anymore.  That’s going to be generated on your cell phone, and with 2.5 billion cell phones in the world now, everyone is walking around carrying the sensor around them all the time.

And the third one, I think, is—as we think about applications, is that there is no golden egg application, or such a perfect application—unicorn application.  And that in order to really deliver new research or outcomes for individuals, you had to leverage the strength of a broader ecosystem of players.  And so, when we built Helix, we built it as a personal genome platform with the user at the center, who gets sequenced and they can control their data in how they see fit, and they can interpret it with high quality partners like we have with the Mayo clinic, or Geisinger.  And we think for everyone, they’re going to have different applications they care about.

And so, some people will come in and say, “My big question for myself is where am I from, and who am I?”  Some will come in and say, “Can I have a health family?” And there will be an application like carrier screening.  And some will come in and say, “What can I do from a preventative standpoint?”  We have partners there like Mayo clinic.  And so, we hope that these applications will help people make better decisions for their personal health, but also provide a broader opportunity to potentially contribute their data to broader humanity, as well.

Wan:                So, say 30 years from now, when everybody’s genome is sequenced at the regular—like going to the bank or whatnot.  How do you see this interacting in their daily life?  So, would it be part of your—what daily experiences would it be part of?

Lu:                   I think that’s a great question, and I think the first part is to realize that if a cost is going towards zero, I think everyone would expect to be sequenced, so everyone in this room today is very likely, if they choose to be, have the opportunity to be sequenced.  The second piece is that I think today, it’s an activation energy to talk about sequencing.  Oh, I’m going to get my DNA sequenced.  But in 30 years, it will be ubiquitous.  So, it won’t be a question, have you been sequenced?  It will be, why haven’t you been?  And the question won’t be, can you show me your data?  It will be, the data already exists there, and so your first interaction with data will not be a DNA question; it will be that the data exists in your health record, and you will just show up and they will know those things about you, and your physician will ask you targeted questions based on the things they see in your genetics, not that you would go in and bring your genetic data to them.

Wan:                In that 30-year scenario, what application would there be for that?  Is this strictly in diet, disease?  Are there things outside of that as well or what?

Lu:                   I think we should think about it not in terms of genetic questions, but in terms of questions that consumers may have, or health questions that the medical system may have.  So, in the questions of pharmacogenetics, which Dr. Collins just talked about, the question would be, how do I deliver you more personalized treatment regiments, and how do I become more healthy faster?  And genetics will play a role in that.

I don’t think you’ll think about it as a DNA test.  It will just be embedded in the system.  You may decide that you want to have a family, and so carrier screening will be de facto; it will be normal to have a carrier screening.  You’ll probably know what diseases you might carry from an autosomal recessive perspective, much earlier in life.  And if you have a family history of heart attacks and coronary artery disease, you’ll have that history, plus your genetic scores, as well, and they’ll be combined to provide you more complete view into your own health.

Wan:                Do you get a lot of questions about the nightmare scenarios of DNA being—discrimination, biosecurity, that kind of stuff?

Lu:                   Yeah.  I actually think what will happen is we normalize access to DNA information is that we’ll start to treat it in the appropriate manner.  I think today, there is this perception that it is your destiny.  I think we are very quickly going to have to dispel that myth, and that will be healthier for everyone, as well.

Wan:                Okay, that’s helpful.  And Dr. Putcha, I’m curious, can you talk a little bit about the state of play for liquid biopsy, for the work that Freenome does?

Putcha:            Yeah, very much, thank you again, William, for the invitation, and thanks to The Post.  Sure.  So, I always shudder a little bit when the phrase ‘liquid biopsy’ is uttered, because it’s sort of come to mean everything and nothing.  And by that, what I mean is that it actually conflates quite a few different applications of effectively looking at things in the circulation or otherwise available non-invasively, whether they be saliva or urine, or something like that.  And trying to glean from that sort of health status that previously would have basically required an invasive biopsy.  That fundamentally is sort of what the promise of liquid biopsies is supposed to be.  But what I mean when I say it conflates a bunch of intended uses for that sort of approach is that if we just take the example of cancer to focus, since that’s really where that technology and that approach currently certainly has the most significant play, is it can be everything from detecting cancer early on, to actually determining how to treat that cancer based on the mutational profile that you see in circulating tumor DNA, to actually effectively monitoring the efficacy of that treatment, and looking for minimal residual disease and things like that.

And the reality is that whether it be from purely a sort of validity standpoint—do you actually see what you think you see and does it mean what you think it means, the levels of evidence that would be required to prove that is one thing, and then similarly, even more so, from a clinical utility standpoint, coming back to comments that were made earlier, if you could detect this, can you actually intervene in such a way that actually has a health outcome benefit?  Those two threads have not been tied together very well, so in many ways, the challenges currently, in my view in the field, are less about the technology and what we can do, than whether if we do it, we actually do benefit the patient.  And do so in a cost-effective manner.

Wan:                In your work especially, I imagine, when you’re at the very outset of something like this, you encounter a lot of doubter, right, whether it’s investment, or regulation.  Have you—what is—how have you developed any way of responding to that?  Or any lessons learned from—

Putcha:            Well, I think—my background is a little checkered, shall we say.  I’ve been on the investor side of this.  Obviously, I’ve trained as a physician in molecular genetics.  I’ve actually also been in startups such the one that I’m in right now, but I’ve also worked on sort of the payer side and the regulator side of this, as well.  And the good, the bad, and the ugly of having those different perspectives is I’m sort of inherently a skeptic, myself.

And so, I think, to be frank, the best proof at the end of the day, is good science and good medicine, and sort of having transparency around that.  So, the threads that I was talking about, sort of very simply, the analytical validity of what you’re doing, the clinical validity of what you’re doing, which is really just saying, “Do you measure what you say you measure accurately and reproducibly?  Does that thing that you’re measuring actually matter?  Is it associated with some clinical endpoint, like the detection of cancer, or drug response that matters?”  And then if you then use that, does that actually prove useful in benefit outcomes?

So, I think at the end of the day, what we would do to sort of—I think the field as a whole has to sort of put up or shut up.  And the best way to do that is to provide the—do good studies that are appropriately sized and powered.  I mean, it’s not the sexiest thing to hear, but at the end of the day, this is how medicine moves forward.  And to answer those questions that, frankly, if you’re a patient, that you would want answered.  Is this—if I’m going to do this, is it actually going to change how you take care of me?  And is that change actually going to help me? Suffice it to say, we don’t need another Theranos on our hands.

Wan:                And Dr. Kraft, I’m curious, you have such a unique perspective from seeing all these fields and how they develop and how it intersects with technology.  Can you talk a little bit about what has you most excited, out of all the convergences between tech and health, in the horizon?  What are you most excited about?

Kraft:              I think the real opportunity here is to sort of shift our mindset about healthcare, which is really much more sick care.  I’m trained in trial medicine, pediatrics oncology.  We have a system now where the data we get, whether it’s our blood pressures, or our genomics, come to us in scattered, intermittent pieces, and so the data flows are broken, and we’re therefore very reactive.  We wait for the heart attack, the stroke, or cancer to present late stage, or someone in renal—a kidney transplant.

I’m most excited about this sort of super-convergence, the ability now to move to much more continuous data flowing through our smart phones and our connected rings, and tied to our personal genetic databases.  And then to be much more individually proactive, as an individual.  If you had your own sort of check engine light for your body, based on your digital exhaust, your sort of internet of medical things.  And including flow to your clinician, your healthcare teams, to pick up diseases earlier rather than later, if you have a disease like diabetes, or anything else, to manage it in a much more smarter, tuned way.

And we really live in this amazing exponential age.  You know, 17 years ago, when Dr. Collins was first sequencing the human genome, there was billions of dollars and millions of dollars; the price of sequencing has dropped to twice the rate of Moore’s law, to a thousand or maybe a hundred dollars soon.  The price of wearables and data are getting cheap.  3D printing is becoming something you can have in your home.  So, I’m most excited about the fact that now clinicians, researchers, and others from different fields can come together to look at how we can match these up to address a lot of the challenges we have across healthcare.

Wan:                Do you—I wanted to ask you a little bit also, all of you up here are—wear two hats.  There’s the medical side, the research side, but also the entrepreneurial side.  I’m curious, can you talk a little bit about the convergence between technology and health, Silicon Valley and medicine, and how is that evolved over the last decade?

Kraft:              One example—I mean, we’re here in 2017.  It’s only ten years ago, essentially, this fall, that the first iPhone launched.  These have become, obviously, medicalized platforms.  My old iPhone 2, this antique, would seem slow and clunky if you had to use it.  It was magical at the time.  The iPhone 10 that’s coming out will soon seem antique.  So, what’s been interesting at least where I come from out of the Bay area, and Silicon—at Singularity University in Exponential Medicine is that you’ve got a lot of folks coming from other technological fields—folks who do machine learning, and built games who want to apply them on our mobile platforms, or are building—my antique Google Glass as well; VR programs, augmented reality, things they could use for gaming are now being played out in the operating room.

The challenges is often these folks are very enthusiastic but a bit naïve to the realities of getting these things paid for, regulated, how a surgeon is going to interact with it versus a patient versus a caregiver.  And sometimes those need to match, but there’s a lot of new energy, a lot of the new beginners mind coming that’s helping catalyze new thinking.

Wan:                Can you talk about—what are some of the pitfalls when you have this kind of—this merging between these two kinds of cultures or these two worlds?  From what you see in recent years, what’s the potential and what’s the pitfalls of some of that?

Kraft:              Well, some of the potential, we talked about all these omics [ph] information, the movie Gattaca, a 20-year old movie, raises some of the issues about what happens when you have your omics and others, and people not understanding it, or applying it in strange other ways.  I finished my—I started my medical residency at Mass General 20 years ago; I can’t keep up to date with all the omics, let alone what’s just published.

So, some of the pitfalls are not allowing it to come to the clinician at that last mile.  If Dr. Atala here is looking at my genome, how is he going to pick the right drug, or right 3D-printed kidney for me?  How do you integrate that, how do you take all the medical information and sift it, and provide it proactively to the consumer, the patient, the caregiver, the pharma, medical industry?  So, that’s one of the pitfalls.

Lu:                   I’d actually just add one point to that.  I think this year it was actually that you have to provide information in a way that’s appropriate to the context of the patient. You want to make sure they understand it however they see fit, and that you can meet them where they are and not necessarily have to bring them all the way to you.  And so, we think a lot about how do you enable an ecosystem of partners, and the right players from all different places, whether or not that’s a large institution, like a Mayo clinic, or a small app developer?  And how do you build localized experiences that help deliver that information at the right point of time?

So, it’s not just like personalized medicine, but it’s also like how do you think about the personalized experience around that?  And that makes it, I think, much more relevant and provides the right context.

Putcha:            I think maybe one other point that I’d just add, especially when you work in the sort of company that I work in, or that many of the folks here are associated with, there are definitely sort of cultural challenges that sometimes happen there.  But it really is that cross-pollination, of course, that is exactly what we’re all talking about that I think is so exciting.  But I think one of the things, especially from the investor side that you have to calibrate them on, especially when you have tech investors going into biotechnology, the cycle time is very different from start to finish.

It’s not 18 months or two years; it’s more like 7 to 10, if you’re lucky, and maybe 4 to 6 if you’re really lucky and really good and just happen to do everything right.  So, I think just setting expectations in a certain sense, some of the challenges in medicine are the challenges in medicine because you start off thinking, oh, well, if we take artificial intelligence, machine learning, and all these things, and apply it to this massive wealth of data that we can learn from our healthcare system, and somehow these things will magically fall out.

There’s a reason these things are hard.  And so, we’ve got better tools, but it will still take us some time to get there, and I think that’s part of what we all learn in the application of these really revolutionary technologies and approaches to age-old questions and problems in medicine.

Kraft:              But I would give to the point that it still takes 10 years, a billion dollars-plus per drug.  We do have the opportunity to reinvent how clinical trials are done.  You can download an app with the clinical trial, you can share—be a data donor, and I like to use the analogy, 10 years ago, we were still using paper maps.  Today, we all drive with Google Maps or Waze.  It’s crowdsourced, including the traffic.  And part of the future, or the near future, is we’ll have a bit of a personal GPS that helps guide us.  It matches our personality type, our omics, helps us, and we share that data to improve the map for all of us.  And we need the pharma companies, the MR companies, the academic groups to start sharing so we can do these things in faster, smarter ways.

Wan:                This question is for any of you, all of you, but we’re in Washington; we’re in a room where some of these very people are kind of involved in regulation.  I’m curious what you think about the role of regulation in terms of how it can accelerate, or also hinder innovation, and how you’ve seen some of those play out in your own work.

Putcha:            Happy to go first, if you want.  So, honestly, I think my approach to that is actually maybe somewhat counterintuitive, because the usual canned answer is, of course, how it hinders innovation and stifles it.  I actually think that, and you know, I don’t believe this is an oxymoron, but innovation appropriately done, can actually facilitate innovation. And the reason I say that is that if it can actually articulate sort of clear and consistent goal lines, level the playing field, and actually, effectively facilitate the innovation by protecting the innovator, then I think that—then I think it actually both facilitates value creation, and the innovation behind it.

And just to give you one very specific example, if I may, of where I believe that is, if you take a look and you just compare, as an example, sort of the situation that we have in diagnostics with this very old discussion about LDTs and how they’re overseen, and you compare that to the situation we have with drugs.  The situation we have with diagnostics and the reimbursement and the value creation there is very different, I think, and no one would argue, than it is for drugs.  And part of the reason for that is that what we basically do is allow, generic diagnostics, or the equivalent of a generic drug to come out on the market, basically at the same time, or even before a branded drug, and then claim whatever it wants.

You can clearly see how that kind of unlevel playing field really makes for a situation where the innovator who goes through the process, develops rigorous evidence doesn’t get rewarded, there’s no incentive to do that.  And on top of that, because of intellectual property and everything, they’re not well-protected, even if they do that.  So, I think that regulation properly done can actually facilitate innovation and create wealth.

Lu:                   I’ll field that real quickly, as well.  I think I actually have a great deal of admiration for the regulators, because they have to see brand new technologies, and make an assessment about how do you regulate something to be safe and effective, in a very small amount of time?  They come in and—you come in and you’re an expert at your field, and they have to basically try to figure out how to become a 30-minute expert in your field.

I think no one disagrees that as we introduce new technologies, that they should be safe, they should do what they’re supposed to do, and they should be effective.  And I don’t think anyone disagrees about those things.  And I think properly done, regulation can be a great accelerant for innovation, that it helps level the playing field and helps prevent people from dirtying the water so that great technologies can emerge.

Kraft:              And with this convergence now, we have digiceuticals.  We can prescribe apps for behavior change, etc. and we did some work—we had the FDA head of digital health come out to Exponential Medicine, we’ve done workshops, and now they’ve launched a sort of softwares medical device element to speed up regulation of drugs, devices, and elements that cross the digital and therapeutic divide, and our pre-check system, kind of trying to speed up and get the regulators to get onto the exponential train, to some degree.

Wan:                Yeah, I think—two things I’d like to bring up.  The first one, of course, is the primary directive is patient safety. That’s why the FDA is there is patient safety, and that’s what we want.  That’s really the most important thing.  But the other thing is as these innovations start to progress through the cycle of the medical healthcare system, we need to make sure that the regulations are actually up to date.  And that they actually address the new technologies, and that is where new regulations that will be specific to new technologies will be important.  It’s not so much that the regulations are bad; they are not.  They are actually quite good, but how can you improve them based on the new technologies?

I wanted to ask you, Dr. Atala, you’ve been pushing on this frontier for so long.  I’m curious what some of the—what are some of the harder lessons you’ve learned, for other fields that are just on the cusp of beginning, like genomics or other areas.  What are some of the lessons you’ve learned after trying to make this a reality for so long?

Atala:              I think really the early lessons learned, where you really—we really tried to make sure that these technologies were proven, and that they were proven long-term, before they actually progressed to large number of patients.  And that’s very important.  If you look at new technologies that came about in the last several decades, like gene therapy for example, and gene therapy was progressing very well, very well, and all of a sudden, a sudden patient death of a child that was very tragic.

And it really paralyzed the gene therapy field, for decades.  It really paralyzed the field because people moved too fast to do something they were not too sure about their safety.  So, I think the main thing with these technologies as they move forward is yes, we want to move as fast as possible to get these technologies to patients, but to make sure that you do have all your Is dotted and Ts crossed before you really cross that barrier to get them to patients and make sure that they really do work out.

Wan:                I’m also curious, all of you up here are MDs, pushing on frontiers, and also working in fields that require entrepreneurship.  And I’m curious what—if you were talking to a doctor just at the outset of making that leap into the world of entrepreneurship, what advice would you have for them?

Kraft:              I think all physicians and clinicians and all of us can be entrepreneurs in healthcare.  One of the opportunities, if you’re a young medical student or resident in the clinic, seeing an unmet need, figuring out new ways to solve it, whether it’s using a chatbot, or a 3D printer, that—in the maker movement, we had a lot of new tools at our disposal to solve problems and then crowdsource the clinical trials, and fund it new ways.  What you could do with molecular genetics as a kid in a high school garage is what a big pharma company could do a decade ago, so there’s a lot of opportunities for us to be finding problems and solving them with a sort of shared mindset.

Lu:                   Yeah, I would say I did my training—I’ve lived in many places, not just the valley.  I spent many years out here in the northeast; I did my training in Texas; I spent some time in the southeast, as well.  I would say that the valley does not have a monopoly on innovation; that there are many people everywhere in all sorts of fields that are interested in how can this be better, and I think we just need to help people get them the right tools, and properly motivate them so they can make their own local impact.

Putcha:            It’s funny because I don’t know about you guys but I get a lot of sort of colleagues or whatever wanting me to talk to their kids about what to do next, and that sort of thing.  And that’s sort of the—it’s always a little bit dangerous to pull on strands of your life, because you don’t always realize all the way that they’re interconnected, and so there are things that I would certainly do differently.

But my advice to them is very much, I think, what Daniel had said, which is at the end of the day, what is the goal of a physician?  What is the goal of what any of us really do, right?  It is really not just to cure disease.  It is to actually prevent disease, and facilitate health.  I think I sent you a question about what the actual biomechanical limit of human life is, and the fact that I’ve never actually gotten a good answer to that question.  And if we could, it’s just not about preventing disease; that is the first step, but it’s a step in the way of sort of improving the—our quality of life.  And so, to that medical student undergrad, high school student, whoever, I think the advice would just be to follow your passion, and if that passion is to actually serve people and try to help them improve the quality of their life, then sort of follow your nose and go where it goes, and don’t take no for an answer.

Wan:                Do you guys have any thoughts on juggling the market pressures with the science that you’re doing, with the medicine applications that you’re trying to make a reality?

Kraft:              I think in a nutshell, it’s not just about the technology, the new app, the device, the widget; it’s blending that with the incentives, and we don’t practice evidence-based medicine, it’s reimbursement-based medicine, and we’re moving into this area of value-based care, paying for things when they work, so whatever system you’re in, wherever you’re in the world, whether we have Obamacare, Trumpcare, something else, we need to think about aligning the incentives to stimulate some of these new innovations, and bring them to market faster.

Lu:                   Yeah, I think it’s about—I agree with this, actually, the statement about how do you align incentives, and how do you, essentially, turn the wheel faster?  How do you kind of do it in the right way, but how do you accelerate research and the outcomes piece?  And how do you leverage, essentially, the convergence of these technologies in order to drive those outcomes that we want?  And I think it’s a lot about how do we think systematically about the incentives, both for institutions, large academic institutions, individual physicians, people themselves—the patients and the participants, as well as the companies that are part of the ecosystem.

Atala:              I think one of the main things, though, is to make sure the risk these technologies internally, in academic centers, and in areas of lower cost before you take them out into a corporate entity.  Because if you do that too early, then the prices—the cost of the technology actually goes up exponentially.

Putcha:            And I’ll add one quick remark, if I may.  There are clearly structural problems in our healthcare system.  What is that saying about Americans will always do it right after they’ve exhausted every other option kind of thing?  Well, yeah.  We sort of do that, so we create bizarre financial incentives in the fact that we sort of have different buckets of money for different aspects of healthcare—hospital services, physician services, drugs, and so forth.  So, it’s hard to have a value-based metric that doesn’t cut across everything that optimizes for both the quality of the outcome and the cost.  So, until we actually start to fundamentally change some of that, I think we’ll continue to optimize within the buckets, and not across the buckets.

Wan:                Unfortunately, I think that’s all the time we have today, but I’d like to thank Dr. Atala, and Dr. Kraft, and Dr. Lu, and Dr. Putcha for joining our conversation, and I’d like to welcome Washington Post’s Kris Coratti back to the stage.

On the Front Lines: The Future of Public Health

Sun:                 Okay, well, thank you, everybody.  I’m Lena Sun.  I’m a health reporter for The Washington Post.  Our last panel for today esteemed guests are going to focus on public health in America.  So joining me on stage, to my left, Dr. Regina Benjamin.  She is the founder and CEO of the Bayou La Batre Rural Health Clinic.  But in 2009, Dr. Benjamin was appointed by President Obama as the 18th surgeon general of the United States, and she served in that position until 2013.  To her left, Dr. Richard Besser is the president and CEO of the Robert Wood Johnson Foundation, a position he assumed earlier this year, and Dr. Besser’s former titles included acting director of the CDC and ABC news chief health and medical editor.  And to my left, all the way, is Dr. Sandeep Jauhar, a practicing cardiologist and a bestselling author.  He is also a New York Times contributing opinion writer, covering health, medicine, aging, and ethics.

Thank you all for joining us today.  I want to remind folks in the audience and those watching at home that you can tweet your questions using the hashtag #transformers.  You can also leave them in the comments section of the Facebook live stream that’s on.  So let’s begin.

I was wondering if the three of you could each spend a few minutes describing for us, as we look forward into the next 20 years, what are the biggest public health threats that you see, and what are some possible solutions.  And to keep your answers to five minutes.  Dr. Benjamin, would you like to start?

Benjamin:        Sure, I told Richard he could start.

Sun:                 Well, one of you—whoever wants to start, jump in.

Besser:             Yeah, I’m happy to kick you off.  Thanks very much for having this panel.  I think having a discussion on public health mixed in with the discussions around technology is important.  When I think about the challenges we face in public health and as we face in the world, there are these big threats of things that can destroy populations—epidemics, massive natural disasters like we’re seeing.  But then I think about what we face every day, and it’s the everyday problems that I think are critically important for us to face as a society.

At the Robert Wood Johnson Foundation, we’re focused very much on what it takes for everybody in this country to have a fair and just opportunity for health and wellbeing.  And as you look at what the drivers are of health and wellbeing, it’s not about whether you have a doctor to go to.  That accounts for about 20% of it.  It’s critically important, and we may touch on the legislation that’s being considered in Washington, and I think the dire impact that would have on people’s access to care.

But that’s about 20%.  What it really comes down to are those factors where we live, where we work, where our kids learn and where they play.  Are we creating communities and a society that makes it easy to be healthy?  That makes it easy to get access to nutritious food and for us to have physical activity.  Where it’s easy for people to have jobs that pay a living wage, so that they’re not working three or four jobs that don’t have benefits and give them access to healthcare.  Are we creating those factors in our society that lead to health?  And I think we’re going to come around to it, as a nation, as a world.  That these are things that everyone should have access to.  And we’re going to take that on.

We gave out a Culture of Prize yesterday, and I was in a little county in central Kansas, Allen County, where this county of 13,000 has decided that they’re going to do what it takes to make their county healthier.  They were aware that people were leaving their county.  There wasn’t a good reason for people to stay.  There wasn’t a supermarket.  There wasn’t a place to be active.  And they’ve taken that on and have decided, “We’re going to make it better”  And those little bright spots around the country give me hope that, as a nation, we can do what it takes to give everyone that sense of the system works for them.

Benjamin:        We’re basically on the same page.  So that’s kind of why I had him start.  But my whole thing is about prevention, and I think that the biggest problems that we have are those lifestyle conditions—the chronic illnesses like diabetes and hypertension and strokes and behavioral health.  And the things that we talk about.  They’re not sexy, but they’re what’s there.  And that’s really what we need to address if we’re going to change health in this country.

One of the things I’m doing in our clinic—I’m back in my little clinic in Bayou La Batre, Alabama.  But we started a health policy research center.  And the reason I started this health policy research center—it’s called the Gulf States Health Policy Research Center—is that it focuses on the five states that border the Gulf of Mexico.  And while we have great hospitals, we have great doctors, we have—even we do have access to care, but something’s keeping our health outcomes poor.  We have the poorest rankings in the entire country.  So it must be something.

I suspect that it’s health policy, so we’re starting to do science- and evidence-based research, using the NIH grant to start this center, to study those.  Things like—if you think my favorite topic, tobacco; in Louisiana, the tobacco tax is about 50 cents a package on cigarettes.  In New York, it’s $5.50.  Those policies matter.  And you will see young people are much more sensitive to price.

Are there other policies around?  We have policies around how many liquor stores are in a community.  Really have outcomes.  And so looking at those policies.  And so we’ve given out grants, and we’ll have a theme issue of a journal coming out.  But those are the type of things we need to do.

But we’re also focusing on the community.  Having the community participate and say, “What is it that we need?”  And we’ve got young people and people who’ve worked in the community, all these years, all of the sudden looking at research and saying, “I’m a researcher.”  As Dr. Francis [ph] was saying, people who were afraid of research, afraid of participating, is now interested in showing some evidence of what they need.  And so that’s the sort of thing I think we need to focus on in the future.

Sun:                 Dr. Jauhar?

Jauhar:             Yeah, I mean, I think that any discussion of public health threats should be framed by an acknowledgement that public health is—public health programs are under threat, and are endangered in a way that they haven’t been in, you know, perhaps ever.

Dr. Benjamin and I were talking backstage, and she said, “Well, public health programs have never been well funded.”  I think that may be true, but the way that the current administration is looking at budget cuts for health and human services, which are going to affect the U.S. Public Health Service, the CDC, the NIH, and so on, it’s important to acknowledge that fact and see that our responses to public health threats are, themselves, may be endangered because of that lack of support.

I took your question sort of literally, which is, you know, what are the couple of public health threats that I see are important in the coming decades?  So, for me, they affect sort of the two most important organs in the body, the brain and the heart.  I’m a cardiologist.  So I think the dementia epidemic has to be acknowledged as a major threat.  You know, today, we have over 5 million Americans suffering from Alzheimer’s, which is only one form of dementia.  And in coming three decades or so, that number is sure to triple.  And unlike other sort of public health problems—chronic illnesses like heart disease and cancer, for example, where there’ve been great successes—dementia really has no treatment.

Compounding that problem is the fact that there is a huge unpaid caregiver workforce in this country that is getting increasingly fatigued by caring for patients, family members who have dementia.  Current estimates are about 15 million Americans are caring for family members without being paid.  The toll in sort of their own mental health, physical health, as well as in lost wages, job productivity, is astounding.  So I think that’s something that needs to be acknowledged, and there’s very little the states are doing about it.

New York State has a sort of pilot program that’s funding a project that will provide sort of supportive counseling and, in some case, subsidize the hiring of help to relieve some of the stresses on these caregivers.  But that’s one state program, and we need to do a lot more.  Doctors need to do a lot more to, you know, actually enquire of family members, “Are you capable of taking care of your loved one?”  I mean, as a physician, I myself don’t really think about it.  But when a niece or a son or a daughter accompanies their parent to a doctor’s visit, I think we just assume that they are going to be available at home.  I don’t think we can make that assumption.

The other big issue I see, as a cardiologist, is heart disease.  And some of you might say, “Wait, heart disease.  That’s old news.”  Or you might say, “Well, heart disease, that’s a huge public health success.”  Right?  And in some ways, it was.  And is.

After World War II, one out of two Americans were dying of heart disease.  And then, due to massive public health efforts, like smoking programs, stopping the advertising of cigarettes, as well as huge medical advances like the heart-lung machine and drugs, the mortality for heart disease dropped dramatically; from 1960 to 2000, dropped by 60%.  But there is very good data suggesting that those levels are leveling off, and maybe on the uptick, for a combination of reasons—increases in diabetes, leveling off of smoking rates, obesity, sedentary lifestyles, and so on.

So, I think that heart disease is still the number one killer in this country, and over half-a-million Americans die of it every year.  So I think that’s something that we have to acknowledge.

Benjamin:        So I have to jump in and mention about the leveling off of smoking.  Can’t be a surgeon general and not catch you on the smoking part.  But young people are really at risk, and sometimes we forget that; that even though we see the leveling off, they’re being targeted—90% of all smokers start before the age of 18, and 99% before the age of 29.  And every day, 1,200 people die from cigarette-smoking in this country.  And each one of those deaths is being replaced by two young smokers.  We call them “replacement smokers.”  So I don’t want us to get lulled in the false level of comfort in saying, “It’s leveling off.”  The young people are at risk.

Besser:             And there’s a lot of variation by state.

Benjamin:        Yes.

Besser:             You know, some states are very open to those taxes, as you were mentioning, and others not.  And some states are open to cities experimenting with more aggressive policy approaches.  And then other states practice something called preemption, where the state says, “Cities within our state are not allowed to do those kinds of activities.”  So—

Benjamin:        And it leads to heart disease, of course.

Besser:             Yeah.

Sun:                 But you know, when you think about these messages, I think the average person might say, “Okay, we know smoking, bad; heart disease, bad.”  It’s difficult if you’re dealing with chronic disease, to come with a new message and deliver that urgency.  What do you see as some way to get around that, to get people to really listen and pay attention?  Because they’ve heard this message again and again.

And I just wanted to follow up on something you said, Dr. Jauhar, about heart disease.  I think it’s kind of interesting that Tom Frieden, when he left the CDC, the thing that he started was to focus on what he thought were the two biggest killers in the world.  And one is cardiovascular disease, and one is fighting epidemics.

Besser:             Yeah.  I think often we put too much of the focus on personal behavior, and say, “Well, you know, if people just would [ph] do the healthy thing.”  And there’s not enough appreciation that the choices people make depend on the choices they have.  And if you’re in a community in a setting where the healthy eating really isn’t a choice, and the streets aren’t safe to go out and play and there aren’t parks, and the schools aren’t providing the healthy choice, it’s not quite fair to say, “Well, if people would just do the healthy thing.”

And if populations are being targeted with marketing of things that are unhealthy, it doesn’t really come down to that sense of it’s just a matter of personal choice.  So I don’t think, after eight years of talking to the public through a camera at ABC, I don’t think it’s just about finding that right message of a lot of the work that Tom Frieden did in New York was putting in policies that kind of took it away from personal choice.  And put in policies that kind of forced behavior in certain directions.

Benjamin:        But the patients that I see do want to do better.  They want their children to be healthier.  They want their families to be healthier.

Besser:             Yeah.

Benjamin:        So we have to make it easier for them.  It’s very difficult to eat healthy and live healthy when you’re saying you’ve got to take care of your kids and then come home and be a caregiver for your parents or your grandparents.  And all the things—most people are now doing two jobs at one time, just trying to keep above water.  And yet, we’re saying, “Okay, you need to go ahead and just eat healthy.”  Well, it’s not that easy.

Besser:             Right.

Benjamin:        So we, as policymakers, really should be trying to make it easier for them.  Take some of those barriers away and do whatever we can.

One of the things that I got in—not really hot water; got conversation about—was when we tried to offer a healthy—a competition for healthy—or not healthy, but most-exercise-friendly hairstyles.  That I thought that was a way to take a barrier away from people who were trying to exercise.  We got a lot of flak over it.  But that’s important when you’re trying to go and work out.  You know, you got to get back to work.

So, anything we can do to make it healthier, easier to be healthy.

Jauhar:             I think that what you’re saying, which I totally agree with, is that chronic disease, heart disease, but really all chronic diseases are social and political.

Benjamin:        Yes.

Jauhar:             They’re not just biological.  And ironically, this idea of biological mechanisms—for example, for heart disease—was advanced by the U.S. Public Health Service.  So by funding a study called the Framingham Study, which really tried to take sort of the psychological component out of heart disease, and really focus on measurable metrics like diabetes and hypertension, whatever, and that sort of advanced this idea that heart disease is driven by these biological factors.  But you know, as Dr. Besser pointed out, these biological factors have so many social underpinnings.

Hypertension, for example, is seen more in poor communities.  We know that poverty and racism, and perhaps even income inequality, drives hypertension in communities.  So we’re going to have to attack the roots of this problem, not just the sort of end product.

Benjamin:        One way we can make some of that a little easier—as I was saying, trying to make it easier—the previous panel, earlier panel, talked about technology, and I think technology may offer us some opportunities to make some of this a little bit easier.

I just joined—I’m newly on a board of a digital health company.  And the reason I joined it is because it may transform the way we can—patients like mine can take care of themselves.  It’s a little—it’s small as, I guess, the tip of a pencil.  But it is a chip that goes into medications.  It’s a company called Proteus, and it’s been in the media.

The chip goes into a capsule, and it monitors when you take the pill, whether you took it or not.  And it also monitors some of your heart rate, or heart effects around it, so you can measure them on your digital phone or iPhone or whatever.  And that way, you know if you took it, you know if it’s responding.  A child has a kidney transplant of something knows whether they can play a sport or not.  I want to make sure that people who don’t have insurance, the people I see in my clinic can also have access to that kind of technology that is available for everyone.  But it may change the way we’re able to personalize healthcare.

Besser:             That last point you made, I think, is critically important, because I hear so many tech panels and one of the words I have from a lot of it is that tech will increase disparities.  That it’s tech for the haves, not for the have-nots.  And I want to see efforts to spur technology to look at how do we use technology to address the health issues for the most vulnerable members of society, and to close some of those gaps.  Because as we’re reading articles about the goal to live to 120, well, I think as a society there are a lot of other things we could be investing our tech dollars in apart from living to 100.  I mean, 120 is great, but—

Benjamin:        Especially if you’re 119.  [LAUGHTER]

Besser:             If you’re 119.  But you know, what about making sure that everyone in America can live a high-quality life?  And for a lot of people, they’re not worried about 120.

Jauhar:             I agree.  I think the impact of technology is potentially revolutionary.  Not just on patients, but also on caregivers.  I wrote a piece recently about a gadget that one can use to—that sort of stores the muscle tremors of a Parkinson’s patient.  You can wear the gadget and experience the tremors of your loved one.  Now, that is hugely important, potentially important, because you know, as I said, there’s a lot of caregiver fatigue in this country because there’s so much chronic disease.  If we can invent gadgets that allow you to experience what diabetic nerve disease is, or muscle circulations [ph] in a Parkinson’s patient, you know, it will improve empathy and improve care.

Benjamin:        To translate this to an international level, these same chronic diseases are the same things in other countries.  The U.N. had its second conference on health with the noncommunicable disease, which was heart disease, diabetes, hypertension.  And it’s starting to affect the budgets of many countries right now.

Sun:                 I was wondering if I could jump in here and ask you folks to think about, in this context of what you’re talking about, looming over this discussion of health, chronic disease, et cetera, is the basic access to care.

Benjamin:        Yeah.

Sun:                 Right?  This all goes out the window if you can’t get access to care.  And if you wanted to spend a few minutes talking about the threat that’s posed by this latest bill in Congress, and if that passes and becomes the law of the land, what that would do to efforts to improve public health.

Benjamin:        The patients that I see, I always describe them as too poor to afford medical care but too rich to qualify for Medicaid.  And so these are the working people who are paying for things.  It’s very difficult for them as it is, and the healthcare legislation that we’re discussing would be very—make it very hard.

However, we’ve always taken care of patients.  We will always take care of them.  We won’t let somebody sit on the—lay on the floor and die.  But it’s much easier when there is resources there, and we can do a better job.  And so I just hope that we as a society will understand how these people live every day, like how all of us live every day, not knowing whether or not we’ll be able to get care, or whether or not my child can.

It’s gotten to the point that it’s so political that you forget there are real people there.  There are actually people, one on one, who have a real life experience with every policy that we’re making and every decision that we’re making.  So I think the access to care really does matter.  I’ve seen over the last couple years just how much it’s been improved.  Just in the last five years.  And so I just hope we don’t go backwards.

Besser:             You know, at the foundation, one of the areas that we’re very focused on is access to care.  We believe that everyone in America should have access to high-quality, affordable, comprehensive healthcare.  That people with preexisting medication conditions shouldn’t have to pay more.  That’s part of our concern over this bill.

The other has to do with Medicaid.  I think there’s a misconception in Medicaid, that Medicaid is just something for poor people.  Medicaid, yes, I’m a pediatrician, and almost half of all children receives care through Medicaid.  But Medicaid also pays for 60% of elderly people in nursing homes.  Medicaid provides for people who have disabilities.  And the idea that it could vary greatly by state, in terms of how those dollars are allocated, is very concerning.  And that states could decide that, well, people who have asthma may have to pay a little more for medical conditions; a child with a birth defect may pay more.  There may be lifelong caps.  We don’t know.  Because it takes away this guarantee, across the nation, that everyone should have access to essential health services.

Anyone who is sick and dying who comes in is going to be cared for, but that’s not what it’s about.  It’s about prevention.  It’s about having a doctor, having a health system that works for you and your family.  And not having to worry.  Not saying, “Well, we’re not going to get those teeth fixed because we can’t afford it.”  I mean, it’s all of this stuff, and it looks like this bill is just slipping through.  And it’s very concerning [ph].

Benjamin:        In Alabama, today, if you make over $250 a month, you make too much to qualify for Medicaid.  And we talk about Medicaid as though it’s for these rich, lazy people.  It’s not.

Jauhar:             You know, when you talk about this bill, I mean, I think the first thing that we have to come to some consensus on—and shockingly, there is still debate about this—is that access to care results in tangible health benefits.  That it results in longer lives.  There is still debate about this that I think is largely politically driven.

There was a piece that Gawande had in the New England Journal recently that sort of really frames the debate, I think, well.  And essentially shows that having access to care helps you live longer.  Helps you deal with health problems better.  It prevents bankruptcies.

So, this bill is worrisome.  I’m not a health policy expert, but Sarah Kliff had a nice piece in Vox recently, where she basically says that this Graham-Cassidy bill is the most radical repeal-and-replace bill that the Republicans have put forth for Obamacare.  Not only will it get rid of the individual mandate, cut Medicaid, get rid of marketplace subsidies.  The current sort of guess is that 32 million Americans will go uninsured in the coming years, I think, by 2026.  That’s awful.

Besser:             We were very encouraged by some of the bipartisan efforts.  You know, the idea that both parties could come together and try to improve on the Affordable Care Act is, I think, something that makes sense and that the American people would like to see happen.

Again, being out in rural Kansas, they’re really worried about rural hospitals being able to survive if there are cuts to Medicaid.  I mean, you must see that greatly.

Benjamin:        Every day.  Every day.  And it’s stressful.  It adds stress to the community when you talk about the things that better health.  Better health allows people to—kids to be better prepared to go to school; they learn better.  Elderly people can stay in their homes longer.  The workforce is healthier.  We want to bring work and economic opportunities, you need a healthy workforce.  And how do you do that without a healthy society?

Sun:                 I had one last question for you all, sort of out of left field, which is, you’re all scientists, you all do your work based on evidence-based medicine—there are many people out there who go to the doctor or come to you and say, “Well, I don’t believe what you’re saying, because this website or this celebrity says, ‘Don’t get vaccinated,’ or, ‘Don’t take this.’”  And because of the internet and speed at which news like that travels, I was wondering, in terms of providing care and for the greater good of public health, how big of an issue is that becoming?

Benjamin:        It’s a big issue.  I think we have to speak to people in a way that they understand it, in a conversation where they understand.  We throw a lot of information—we’re always telling people what you can’t do: “You can’t eat this”; “You can’t do that”; “You can’t do this.”  Why don’t we start telling them what they can do and how they can be healthier?  And make it more positive.  Because you get tired of hearing how negative things are, and being more positive.  But also just breaking it down into very everyday conversation that the everyday person can understand.

The other thing is that there is a lot of misinformation out.  And when someone is set in their ways, you sometimes can’t change their minds.  And we have to accept that.  We have a little saying: “You can’t argue with stupidity.”  You know, some things like vaccinations and some things you just can’t—you just move on and try to educate the rest of the people who are willing to learn.

Besser:             Yeah, I think this is a really critical issue.  And the question of who are the trusted voices in society, and how do we ensure that, as healthcare professionals, we remain or regain that trust.  It’s one of the things we talk about a lot.  How do we be a trusted nonpartisan voice?  Not a voice yelling across the divide.  But one looking to bridge that divide with facts, with science, with reason.  And I’m not sure how we do it.  I know media is very concerned about this as well.  But it’s a big issue.

Jauhar:             I think medicine also—doctors need to take responsibility for the fact that our patients are going to these—you know, these alternative websites, which are very often populated by quacks.  You know, I mean, so you have people going to—well, you know, Gwyneth Paltrow’s Goop and sort of adopting these potentially dangerous things, like vaginal steaming and jade eggs and all that.  I mean, why are they seeking that?  You know, maybe we need to do a better job with our patients, spend a little more time with them, communicate what really is sort of evidence-based.

Benjamin:        Finally, I would just say that I think education is so important.  While most people don’t link it with healthcare, it is so important to have an educated society.  We are dumbing down our entire masses.  And if you don’t understand basics, it’s hard to communicate.  And you can’t participate in a democracy if you don’t understand it.  And so I think we need to put more resources into educating our K through 12.

Sun:                 Thank you very much.  I think we’re going to have to wrap up.  That’s all the time we have for today.  I want to thank all my panelists—Dr. Benjamin, Dr. Besser, and Dr. Jauhar—for being here with us today, and for this great conversation.  I’d like to hand things off to my colleague, Sally Quinn, who will be interviewing Dr. Deepak Chopra.  Thank you very much.

Transformer: Deepak Chopra

Quinn:             So, hi, everybody.  I’m Sally Quinn.  I’m the founding editor of OnFaith, a blog here at The Washington Post, and also the author of Finding Magic, which was just released last week.  And my publicist insisted on bringing my book out.  Of course I think it’s shameless, but what could I do?  Anyway, I know that you all know who Deepak Chopra is.  I’ve known him for ten years, and he was one of the first people I interviewed with OnFaith, and I have revered him ever since.

He’s the founder of the Chopra Foundation and cofounder of the renowned Chopra Center for Wellness in Carlsbad, California.  He’s also a best-selling author and a pioneer in the areas of integrative medicine and personal transformation.  I’m thrilled to welcome him to The Washington Post today as our keynote speaker to talk about his remarkable career as a health and medical transformer.

So, Deepak, why don’t you—well, just let me say this: when I first interviewed Deepak ten years ago, he was not exactly mainstream.  And he came into the studio and he had—you don’t have your flashy shoes on, but he had on these incredible sneakers that were—I think they lit up in the dark and they went—and he had these fabulous glasses with rhinestones and he had this incredible Indian thing on.  And I just thought, “What is this?” you know?  I had no idea what to expect.  And I sat down and I was riveted.  I mean, we were supposed to have an hour interview and it went on for at least two hours; we had to cut it way back.

And then he came to Washington about six months later and I had him for dinner, and my husband, Ben Bradlee, was there, and Bob Woodward was there, and they all kind went, “Oh really, Deepak Chopra?”  And they didn’t leave the table until 1:00 in the morning.  They were completely blown away by Deepak and everything he had to say, which was really—talk about transformative; it was incredible.

Now, Deepak, I don’t know whether—

Chopra:           By the way, I’m about to go off mainstream again. [LAUGHTER]

Quinn:             Well, I was just about to say I am so sorry to tell you that you are now mainstream, and I don’t know whether that’s good or bad [LAUGHTER].

Chopra:           I usually hang out with the sages, psychotics, and geniuses.  It’s a motley group of strange people.

Quinn:             So why don’t you tell us a little bit about how you got into the wellness biz, and then I have some questions to ask you.

Chopra:           I’m an internist, endocrinologist by training.  And I trained in the 1970s and got especially interested in neuroendocrinology.  And when we were residents and fellows, there was a revolution going on because of a new technique called radioimmunoassay.  So you could look at peptides in a way that you couldn’t before that.  And there was a lot of talk about neurotransmitters, neuropeptides, and very early on I had the intuition that emotions correspond to biological states, that, of course, we know if you have stress, you have a certain kind of biology and if you have joy or you fall in love, the biology is quite different.

And, of course, today we can identify a lot of these neuropeptides, as you call them.  I call them molecules of emotion: serotonin, dopamine, oxytocin, opiates, and a new one called anandamide, which is the peptide for bliss or happiness.  Happens to be an immunomodulator.  So it’s been a long journey.

Quinn:             Can you buy that? [LAUGHTER]

Chopra:           No, but you can generate it if you fall in love.

Quinn:             Just like that, huh?

Chopra:           Just like that.

Quinn:             So, anyway, you write about—you’ve done this book the, You Are The Universe, and he’s got a book coming out which nobody has even seen, but I’ve seen a lot of it, called The Healing Self, which is riveting.  And it just touches on everything about your wellbeing.  But you have six pillars of wellbeing, and why don’t you tell us what they are?  Because I think everybody needs to know exactly.

Chopra:           So I should preface that—I’ll answer your question—by saying that only 5%—and, unless you’re really in the know right now, you may or may not know this fact—only 5% of disease-related gene mutations are full penetrant.  So if you have a gene mutation for a disease, a chronic illness—heart disease, cancer, autoimmune illness, whatever—only 5% of those mutations are fully penetrant, which means they predict the disease.  If somebody has a gene like the BRCA gene, for example, or certain types of Alzheimer’s genes—

Quinn:             That’s the one that Angelina Jolie had?

Chopra:           That’s the one she had.  Then that’s fully penetrant, it predicts the disease.  95% of disease-related gene mutations are related to lifestyle; they don’t predict the disease, they make it more likely that you will have the disease, but it doesn’t mean that you will have it.  So this is a new era with epigenetics, with neuroplasticity, with what we know about the microbiome, the fact that your body’s an activity that is constantly, constantly being influenced by what’s happening in your life, that which we call experience.

So six pillars: sleep—actually, one of the biggest predictors of Alzheimer’s is lack of sleep and lack of sleep causes inflammation in the body.  It also causes disruption in the microbiome, it causes amyloid accumulation in the brain, and it is a predictor of premature death.

Quinn:             Well, like how much sleep do we need really?

Chopra:           Well, ideally speaking, seven to eight hours of restful sleep, not induced by a tranquilizer or a sleeping pill or alcohol.

Quinn:             But you see all these really powerful, successful men—people like Bill Clinton who claim—

Chopra:           Oh, we have a president right now who doesn’t sleep.

Quinn:             Or the president now, who says he only needs three or four hours of sleep; he’s tweeting at 5:00 in the morning.

Chopra:           It’s not true.  If you are lacking sleep, your body is going to have inflammatory molecules that are way up, and it’s a predictor of many chronic illnesses.  So anybody can check out the evidence.  Number two pillar—so that’s number one—number two is stress management in any way or form.  Of course a reflective self-inquiry, contemplative practices, meditation, et cetera, very useful in decreasing the biological consequences of stress.

Quinn:             Let me just ask you about stress because there’s stress and there’s stress.  I mean, you know, a lot of us are busy and we’re running around and we’ve got all these things to do and there’s stress in our lives and the kids and the dogs and college and salaries and may have fought with your boss, and then there’s stress like you’re in the middle of a war or you’re in the middle of a hurricane or you’re in the middle of an earthquake and everybody around you is dying and your life is falling apart, and that’s a different kind of stress.  So how do you manage stress when you’re in a really—or that you know one of your loved ones is dying.  How do you—

Chopra:           Well, the stress is a response to threat, so it’s a biological response to a physical threat or psychological threat, and it’s a protective response because your cortisol goes up, your adrenaline goes up, you prepare for what is called the fight-flight response, and if your house is burning, you need to run out.  If somebody mugs you, you need to protect yourself.  In a war, stress actually helps people in combat.  But if it’s a longstanding, chronic, inappropriate stress, which is an exaggerated response, a flight-fight response to maybe a Tweet, then that kind of low-grade chronic stress will wreak havoc in your body.

Quinn:             Okay.  Next one.

Chopra:           Number three is movement and exercise, which, for me, particularly now with all the research that we are doing on yoga, mind-body coordination, and breathing techniques, you can actually show that our entire civilized world is on what is called sympathetic overdrive, and they’re always, in that response, ready to go to war.  And mind-body techniques like yoga, breathing, tai chi, chi gong, all the eastern martial arts are extremely useful in restoring homeostasis in your body, or what we call self-regulation.  So that’s number three.

Quinn:             So when you say “movement,” how much movement do you need?

Chopra:           10,000 steps a day at least.

Quinn:             Which is—well, how many hours would that be a day?  I mean, I know you wear these little things.

Chopra:           It depends.  I spend a lot of time in New York, I don’t have to do anything other than walk to wherever I’m going and 10,000 steps is not a big deal at all.

Quinn:             A half an hour, an hour, something like that?

Chopra:           It’s approximately five miles a day.

Quinn:             And you talk about yoga a lot, but you don’t mention other—like running or playing basketball or football or other—

Chopra:           They’re all extremely useful, but yoga is very specific in that it stimulates what we call the vagus nerve, which is the tenth cranial nerve.  It goes from your midbrain; it influences your facial expressions so you can tell your mood; it influences the tone of your voice, if it’s friendly or stressed; it influences something called heartrate variability; it influences the bioregulation of organs in the body, and it also influences the microbiome, which is two million genes in your body which are not human but bacteria.  So yoga is very targeted to self-regulation because of the way it influences what we call visceral nerves, not the nerves that go to your muscles.

So most exercises are about muscular activity; yoga is about muscular activity as well as self-regulation in the viscera.  And now there’s a lot of interest in the pharmaceutical industry in what they call bioelectric medicine, and people have found that even if you stimulate the vagus nerve with a device, electromagnetic device, it helps in intractable epilepsy, it decreases inflammation, may improve your asthma, reverse things like rheumatoid arthritis.  This is a very cutting-edge area that needs to be explored a lot, but there’s enough literature to say that yoga is not the same thing as exercise.

Quinn:             So what about number four?

Chopra:           Number four is emotions.  This is very interesting because all these years we’ve studied the emotions of anger, hostility, stress, running out of time, all the things that—you know, major epidemic of modern civilization.  But very few people have studied the role of emotions like gratitude, for example.  We did a recent study, which was published in a peer-reviewed journal, where people kept a gratitude journal at night and their inflammatory markers go down, and all their symptoms.  This was a study we did with chronic heart failure patients, and they had remarkable responses just by experiencing gratitude in a journal, writing down all the things they could be grateful for.

But we also know that love, compassion, empathy, joy, equanimity or peace have their own biology.  And this was not known 30 years ago.

Quinn:             But, again, there are emotions that are legitimate emotions about, you know, your husband is abusive or he’s having an affair and walks out, or your wife, or your child is being bullied at school or you’re sad because somebody dies.  Those emotions are things that are thrust upon you.

Chopra:           As long as you’re not a bundle of conditioned reflexes and nerves that’s constantly being triggered by people, circumstances, and events into predictable outcomes, as long as you’re aware of your reaction to react, and as long as you consciously react, then even those emotions can be useful.  After all, emotions have biological functions, so anger readies—in evolutionary theory, anger readies an animal for combat; fear readies an animal for flight; disgust warns mammals of the likelihood of contamination of nauseous foods.  So all emotions, whether even guilt, depress, humiliation, shame, they’re not found in all mammals; they’re only found in primates and humans, where there’s a social hierarchy.  They inform mammals of their status in the pecking order.

So when you look at emotions, they have biological reasons, and they are meant for survival, even the negative emotions you’re talking about.  But when they’re inappropriate, that’s when you get chronic illness.

Quinn:             Okay, where are we now?  Number five?

Chopra:           Five is nutrition.  So today, our food mostly, industrial food production is contaminated mostly with petroleum products, Agent Orange, in the food.  So anything that is manufactured, refined, processed, has antibiotics, has hormones, I’m going to stay away from GMOs because that’s very controversial at the moment.  But if your food is contaminated and has poison, hormones, antibiotics, petroleum products, it inflames the microbiome and it does so as soon as you’ve eaten the food.  And these are two million genes that speak to the 23,000 human genes, and so the connection between the epigenome, the genome, and the microbiome is very important and it’s influenced by food.

Now, when I was in training or even in practice when patients came to me and said, “I changed my diet and I had a remission,” I would say, “No, diet has nothing to do with it.”  We can’t say that anymore.  Diet influences your gene activity from meal to meal, okay?

Quinn:             Well, I just finished—when I saw you, I hadn’t seen you for a while and I said, “You look great,” because you’d lost weight.  Was that something that you did consciously?

Chopra:           I’m very involved with the research on epigenetics and microbiome and we are looking now at the effect of plant-based diets and even—

Quinn:             Are you a vegetarian?

Chopra:           I am a vegetarian, yes.  And plant-based diets are much more healthy for the microbiome.  Even meat-based diets in a Mediterranean diet aren’t bad, except for the fact that meat, as we normally get it in the U.S. and in most of the western world, is animals that come from factories that have been given growth hormone, sometimes estrogen, other hormones, antibiotics, and that’s the problem with industrial food production.

Quinn:             And what’s number six?

Chopra:           Number six I think most people may not be familiar with it, but we are very interested in doing a lot of research on it.  How many people have occasionally walked barefoot on the beach?  On the earth, grass?  Okay, so when you talk barefoot on the beach, you feel better, I’m sure.  And the reason is that when you ground yourself to the earth, negative ions come from the earth into your body and they neutralize the excess free radicals that have built up and that cause inflammation.

So we’re looking at grounding, as we now call it, and the effects on inflammation in the body, on sleep, on chronic disease, on stress management, and, very importantly, on restoring circadian rhythms when you have jet lag.  So when you have jet lag, it’s because your biological rhythms are out of sync with the circadian rhythms, which is a consequence of the earth spinning on its axis.  But circadian rhythms are tied to seasonal rhythms, lunar rhythms, gravitational rhythms.  We are part of the symphony of the cosmos.

Quinn:             But when you say “grounding,” does that literally mean you have to walk barefoot on the ground?

Chopra:           That’s it.  We are the only animal that doesn’t, by the way [LAUGHTER].  We are the only—

Quinn:             So we should just take our shoes—everybody take your shoes off right now.

Chopra:           But not here.  You have to ground yourself to the earth.  You have to ground.  You know, also, by the way, now tree hugging has a new rationale.  If you hug a tree with your bear skin, you get grounded as well.

Quinn:             Is that right?

Chopra:           Yes.

Quinn:             When they made up the thing about—I mean, because the environmentalists used to be sort of joked about as tree huggers.

Chopra:           Called tree huggers with disdain.

Quinn:             But that came from a real thing about how grounded you could get if you—

Chopra:           I’m saying that it is.  As usually, whenever I say things, they’re controversial and people will say, “What’s the evidence?”  Well, we have lots of evidence now that contact with nature in any way—you know, we think of ourselves as organism here and nature out there, but those trees are your lungs.  If they didn’t breathe, you wouldn’t breathe, and if you didn’t breathe, they wouldn’t breathe.  The earth is recycling as your body.  The rivers and the oceans are recycling as your circulation.  This air is your breath.

So any time you’re close to nature, you actually sync in your biological rhythms—and there are many of these: circadian, seasonal, lunar, gravitational—but you reset your biological rhythms.  You do the same thing when you sleep, by the way, to some extent.

Quinn:             So that’s six, but there’s one more I want to ask you about, and you alluded to it in The Healing Self and you alluded a little bit to it when you first started talking about how falling in love makes you feel good, and that’s sex and sexual activity, which you allude to earlier in your book.

Chopra:           Yes, I didn’t talk about—

Quinn:             So why is that not number seven?

Chopra:           Well, actually sex and spirituality both are very important, as one is an outlet for your biological expression—there’s no biological organism upwards of rodents or even reptiles that doesn’t have sex.  Even paramecia have sex, so sex has biological reasons for it, but I also believe that sexual activity is, in a sense, a transcendent experience, so when you have transcendence, you touch a part of your self which is not in time.  Time is a result of subject-object split, but deep love, sexual peak experiences, transcendence and spirituality are inseparable.

The religious experience, by the way, is always three things.  One is transcendence.  That means going beyond subject-object split, no separation between the observer and the observed, between the lover and the beloved, the seer and the scenery.  So transcendence, which is a timeless experience, and when there is timeless experiences, your biological clock slows down as well.  I can give people that experience just now, if you want, without sex [LAUGHTER].

Quinn:             So would you—

Chopra:           So one is transcendence.  The second is the emergence of platonic values like truth, goodness, beauty, harmony, love, compassion, joy, equanimity.  And the third is the loss of the fear of death because in every spiritual tradition, there’s a part of you which is not in time.  So when you have that experience, religious experience or spiritual experience, you lose the fear of death.

Quinn:             So would you say that the sexual experience would contribute to wellbeing and therefore to your health, to your good health?

Chopra:           Yes, in many traditions in the world, sex and spirituality are the creative expression of the same consciousness.

Quinn:             You talk about spirituality and it’s something I’d like to talk about.  We don’t have—we’re just running out of time.  This is too interesting.

Chopra:           There is no time—[OVERLAPPING]

Quinn:             I know, there’s no—he doesn’t believe in time, by the way.  But you also—

Chopra:           It’s a human construct.

Quinn:             You also did mention—I mean, where does God—what’s the difference between God and spirituality?  And where—and you can answer this in one minute—and where does that fit into wellbeing?

Chopra:           Spirituality is best defined as self-awareness, self-awareness.  The more you are aware of your innermost being, the more you’ll be aware of everything outside because everything outside usually represents your conditioned mind.  So that part of our self that we call core being or consciousness is not in time.  I can ask everyone to actually have that experience in one second.  As you’re listening to me right now, just turn your attention to that which is listening.  So as you’re listening to me, just turn your attention to that which is listening.  And that what you’re experiencing now is awareness.  It’s not a thought.  A thought might be saying, “I wish I’d gone to the bathroom before I came here.”  A thought is fluctuation in awareness, as is an emotion, as is a perception, as is any experience.  But behind all that is a timeless factor, which is just awareness.  And when you’re just aware, which we call “being,” then you have returned to your source; you’re holy and you’re healed.

Quinn:             So if we follow all of these pillars of wellbeing, obviously all of us want to be well, but what happens when we get cancer or we get some horrible disease?  I mean, all of us know people who are suffering from a disease, and some are people who follow or seem to follow all of these pillars, who work out and eat well and everything.  And so it makes me wonder how—are we responsible for our illnesses?

Chopra:           I mentioned earlier only 5% of disease-related gene mutations are fully penetrant.  The rest are influenced by your lifestyle.  But as we move into the future, by the way, all of our ability to look at and target specific gene mutations, the future is precise, it’s personalized, it’s predictable, it’s preventive, it is participatory.  So we are going to have a very bright future very soon because of our ability to target specific mutations but also see what is happening in our life that is causing a specific disruption.

So one of the big projects now in the world is not the Genome Project, which was big for its time, it’s the epigenetic road map, which means how do we look at what is happening in a person’s lifestyle, in relationships and social interactions and environment, in food, in the mind, in the emotional world, and how is it affecting which aspect of your biology?  The fact still remains that, until now, biology is very unpredictable.  You can have two patients who have the same illness, see the same doctor, get the same treatment, have completely different outcomes.  So biology is unpredictable.  We cannot, at the moment, say who’s 100% likely to get a certain disease, other than the fact that we know the 5% fully penetrant gene mutations.

We are not responsible, but I think society has a responsibility collectively to minimize our propensity to disease.  If there’s one factor that underlies all diseases, by the way, one thing that underlies all chronic illness—I’m not talking about infectious disease, but one thing that influences, is the underlying factor in every chronic illness—cardiovascular, cancer, autoimmune—it’s inflammation.  And inflammation has lots of causes, but an inflamed mind will cause an inflamed brain will cause an inflamed biology will cause inflammatory relationships, and ultimately a violent world.  We are not looking at violence as a public health problem right now, but it is.  And if you don’t, we are declaring our insanity.

I think personally that violence, climate change, disruption of our food chain, hostility, social injustice, economic injustice, environment have all to be addressed if you want a holistic way of looking at health.

Quinn:             I am so sorry we are out of time, and I just want to thank Deepak for being our guest today.  And if you would like to go back and watch tonight’s full program or selected video highlights, you can access them at washingtonpostlive.com.  And a reminder to our local people is Deepak will be back in town November the 28th.  He’ll be talking about the future of wellbeing at the Strathmore Music Center in Bethesda.  Thank you very much for being here, and I’m sorry that we didn’t have more time to go on because he knows a lot more.

Chopra:           Thank you.

Quinn:             Thank you.

Sponsored Segment: Future of Healthcare in Five Words

Frans van Houten, Philips:      Well, we heard a fascinating panel about all the innovations that are possible in healthcare.  And I can assure you that Silicon Valley does not have the only right to innovate in healthcare.  I mean, I am the CEO of Philips.  Philips is a $20 billion innovation company in healthcare.  And we dedicate ourselves to improving the lives of, already today, more than 2 billion people every year.

But what we heard from many panelists is absolutely true.  Right?  It is not easy to innovate, and it is a complex landscape.  You need to integrate it.  And incentives are not always lined up.  So I can absolutely relate, as the leader of Philips, to this discussion.

Yet here we are, extremely motivated to innovate, to improve lives.  Because that’s what the world needs.  Growing population, aging population.  Evermore people with chronic disease.  We got to innovate to actually either prevent or resolve all these issues.

So as part of my contribution of this fascinating afternoon, I just thought to give a couple of thoughts around how we at Philips look at the evolution of healthcare.  Both the pretty and maybe the not-so-pretty.  And I thought to do it in a new way, and that is basically by choosing just five words to talk about healthcare.

Now, to frame it a little bit, I think we all are aware of the staggering cost of care.  Here in the United States alone, you know, 3.3 trillion annually, more than $10,000 per person, 18% of GDP; 4 billion annual prescriptions dispensed along the way.  And that’s just United States.

I have here the Sustainable Development Goals button from the United Nations.  I was in New York earlier this week.  And you know, we see that the world at large struggles with healthcare; certainly the U.S. is not the only country.

So, there is no escaping these big figures that are involved, and that means that we need to look at it through a different lens.  Or to paraphrase Oscar Wilde, he said, “We should not just be guilty of knowing the price of everything.  But the value of nothing.”  So obviously, it is about value and not about just the cost.  The costs are merely the consequence of how we work, the inputs that we throw into it.

So, here comes my first word.  The first word that I think is the most important word for the future of healthcare.  And it is not cost, but it is outcomes.  In healthcare, outcomes are actually the reason why we all get up in the morning to contribute.  Whether you are a doctor or a scientist or an innovator or a businessperson in healthcare.  Outcomes really is where we are going.

The Quadruple Aim is something that motivates us a lot.  Driving better outcomes at lower cost while enhancing the patient and the staff experience.  So if we can improve that, we are going in the right way.

But as an industry, we are not always geared up to measure ourselves against outcome, let alone to hold ourselves accountable for those outcomes.  As we heard about incentives that are misaligned, we still very often reward activity for volume rather than outcomes.  There is very little reward for prevention; whereas if we can detect disease early and prevent it from aggravating, hey, that would be the right thing to do, but there’s not always reimbursement for that.

We put also relatively little emphasis on integral patient-centered personalized care, with first-time right diagnosis and precision medicine.  If we get it wrong, we simply do it again.  You know, that kind of stacks up cost, and I think it is important to see the holistic picture of all these inputs that we put towards a patient’s care.

So we need to look holistically.  And therefore, by adopting the word “outcomes,” we also need to measure better.  And I believe that technology—and especially digital technology—can help measure outcomes better.  And not as a photo moment, but as a continuous process.  And at Philips, we really try to make data measurable and actionable towards better outcome, better outcome optimization.

So that’s the first word.  Now let’s make the problem a little bit bigger and go to my second word.  And that is “inclusion.”  I just kind of referred to, you know, the United Nations’ Sustainable Development Goals, and Goal #3 is to give access to all.  Access of health and care to everybody.

And we are not going to fix all the world’s healthcare problems overnight, obviously.  But we can also not transplant the high-cost solutions of the Western world to remote communities in the developing world.  There’s over 2 billion people today that don’t have access to care, as a matter of course.  And that is very, very painful.

So if we stay outside the United States for a moment, in Africa, Philips has been developing what we call “community life centers,” in some of the most disadvantaged areas, in an attempt to rewrite the rules on inclusion and equal access to care.  But we have not focused on just trying to cure sick people.  Because that would be the wrong solution.  It’s about building capacity in these communities where we integrate technologies and services towards basically a hub for the village to prosper.  A combination of vital primary care, which is as important as, you know, clean energy or solar energy, clean water, hygiene, safety, and education.  Bring that together and the village starts to prosper.

This is actually a technology package that includes healthcare equipment to enable patient monitoring, diagnosing, and triaging—laboratory equipment, refrigeration.  Think about the last mile for vaccination programs.  Water supply and purification.  Think about the prevention of waterborne diseases, and so on.  And then of course, the sort of lighting [ph] for security and extended opening hours.

By the way, we have such a center in the work zone in the north of Kenya, Mandera County.  Drones are delivering the medication supplies in a safe way.  Isn’t that cool?

So, the possibility for inclusion, obviously, also applies to mature economies.  More than 15% of the U.S. population lives in rural areas, where millions of Americans face pressing health needs amidst physician shortage, and still high rate of hospital closures.  In fact, according to population health experts, the ZIP code may well be the single most important factor determining whether you will get the care that you deserve.

And we admire how Lost Rivers, hospital in Idaho, is using cloud-based technologies to help communities achieve high quality of care, at low cost, through actually systemwide integration.  Hub-and-spoke models.  Data sharing.  Streamlining of referrals—often referred to as telehealth.  And this can make health also accessible and affordable for the people who need it.

So technology can close the gap between the haves and the have-nots, but it does require a new way of working.  And as the panel was referring to, maybe then also different ways of reimbursement.  Because very often, telehealth is not easily reimbursed.

There we go.  My third word is about productivity.  As an industrialist, you could not live without the word “productivity.”  You may think that’s a little bit of a dry term that companies like, but I would like to share a broader perspective with you.  Actually, it is pretty important, especially, I think, for healthcare.

But I’m going to make a sidestep to an altogether different field of industry.  As Warren Buffet has noted, productivity lies at the heart of American prosperity, and its role is largely underappreciated.

In 1900, American civilian workforce was just 28 million people.  Of these, 11 million, or 40%, worked in farming.  The leading crop, as now, was corn.  About 90 million acres were devoted to the production of corn and the yield break was about 30 bushels.  That gave an annual output of 2.7 billion bushels.

Then came mechanization.  New innovations on planting, irrigation, fertilization.  And today, the U.S. devotes approximately the same geographical area to corn as in 1900; in fact, a little bit less.  But productivity has improved yields more than fivefold, while labor force participation has fallen from 40% of the population to just 2%.  So, that is productivity for you.

I contend that the Digital Age has as much to offer as the Industrial Age in enabling the way we can then transform healthcare through productivity.  And one example is the introduction of techniques, like lean, Six Sigma, variance analysis—just for all of us, variance.  If one doctor helps you and there’s a different outcome from if another doctor helps you, that’s variance.  Or if one doctor does it at twice the cost than another doctor, that’s variance.

So if we get everybody to adopt best practice, which is common under, let’s say, the lean mantra, then we can drive tremendous efficiencies.  And of course, there are many best practices, and I’d like to call out one that I admire, and that is Intermountain Healthcare, here in the U.S., who has transformed its supply chain to achieve a radically lower cost structure.  And the result has been significantly lower cost for their patients and communities.  In fact, they saved as much as 2 billion in savings over the last five years.  In 2016 alone, Intermountain Healthcare built 700 million less than they would have built if they had not transformed the way they provided care.  They did not have fewer patients; they served more patients with less money.

So, we are talking about designing scalable, repeatable processes and workflows that optimize patient care delivery.  For example, Kaiser Permanente outpatient contact, more than half of their outpatient contact is actually delivered through telehealth.  And we will see a lot of innovation coming in the near years to come.  Artificial intelligence, machine learning, to augment human expertise.  All of that will help tremendously drive people productivity.  Doctors, nurses, they will still be needed, but we can, through technology, make them more effective.

And this is why at Philips we put a lot of emphasis on so-called clinical informatics, to improve workflows and apply artificial intelligence to make doctors more productive in, for example, understanding how Alzheimer’s is progressing in the brain, which is a very tedious study that can take over an hour for a neuroradiologist to perform.

So when you think about the care experience, it is fair to say that you go from department to department.  Yes, I’m heading up to my next word that I will disclose to you in a moment.  So imagine you’re a patient, you go into the hospital; you go from department to department.  And we experience the health systems sometimes as a little bit siloed.

Every part and every member of the health system will strive for excellence in their own right.  Everybody wants to do a good job.  But altogether, the patient is being handed over from station to station, and the experience may be a little bit less than ideal.

Integral care processes can certainly help for a much better patient experience.  Think of people with multiple chronic conditions.  Today actually accounting for 7 of 10 deaths per year, 86% of U.S. healthcare cost.  Many of these people very often go back to their healthcare professionals; they very often revisit hospitals.  And they are, let’s say, confronted with the lack of the integration of care.

Our own research that we have published some time ago shows that just 1 in 10 healthcare professionals and only about a quarter of Americans consider that the healthcare system is well integrated.  In other words, seamless.  That is my fourth word.

I think if we can improve the integration and thereby the seamless experience for patients, we will also get to that higher productivity.  We will get to better patient outcomes.  Seamless care will change the patient experience by joining up the dots.

A practical example, perhaps, coming out of Karolinska University Hospital in Sweden—they are one of the world leaders in stroke treatment.  And stroke often happens while you’re at home or in the office, and then 911 is called.  And at that time, it is critical to get you into the hospital to take the blood clot out of the brain so that there is no permanent damage to the cognitive functions of the person.

So, it’s called the alarm or the call to needle time that needs to be optimized, and they gave actually Philips a challenge to say, “How can you help us improve the call to needle time to less than 90 minutes?”  Because that is the critical window of opportunity.  And together, we redesigned the entire stroke care pathway, to make it seamless, to take all the waiting time and the waste out.  Triaging now happens in the ambulance rather than in the hospital.  The emergency room is bypassed; the patient straight goes into the hybrid operating room, where they are operated, because the data is already available, as it was transmitted in advance while the patient was still in the ambulance.

This is an example where precision diagnosis, predictive analytics, data integration all come together in a wonderful opportunity to really help patient outcomes and productivity at the same time.  And as this patient was helped and then moved maybe in the ICU for observation and support, and then later on, to the general ward and then to the home, it’s continuously being monitored so that we know that that healing process is happening in the right way.

And we see some very exciting examples here, in the United States, applying these kind of integrated care technology concepts.  Seamless care, applying telehealth, and remote oversight from the ICU to the home.  Banner Health in Phoenix is actually a very forward practitioner of this kind of integrated care, and they were able for their most sick patients, reduce cost by 34%, lowering hospitalizations by 45%, and reducing 26% fewer deaths.

What also came out of the study is that the patients that were part of this telehealth program were much happier because they did not have to go to the emergency room a couple of times per month.  So it improved their quality of life.

Another example here out of Upstate New York, Westchester Medical.  They’re using telepsychiatry to knock down barriers to care—make it easier for patients to actually stick to their treatment, keep their appointments, resulting in a fourfold reduction of cancelations and no-shows, and millions of savings.

All of these are examples of improving the experience, and that is what the word “seamless” describes, what the care experience should be.  This is also why we at Philips don’t want to be a supplier.  We think that the word “supplier” is wrong.  We don’t want to deliver a piece of technology and then turn our back.  We would much rather be a partner.  A partner who makes technology work for healthcare.  A partner that will drive better outcomes and higher productivity.  A better patient experience as well as a better staff experience.  Taking a holistic view to innovation.

We are doing quite a lot of pioneering work here, in the United States.  By the way, I may use the opportunity there to say that, you know, 33% of our global research and development is done here in the United States.  And we produce most of our equipment also in the United States.  We are a net exporter from this continent.  And we do a lot of clinical research together with leading academic hospitals here, in the United States.

And that brings me to my last word, the fifth word.  That’s the word “innovation.”  Perhaps a word that is overused, but we love it.  We are an innovation company.  We are 126 years old.  You don’t live as long as 126 years unless you reinvent yourself from time to time.  And that reinvention actually comes out of a commitment to research.  But you cannot do all that research on our own.  In fact, we need to do it with other people.

Now, out of the almost $2 billion in research and development, more than half is in software and artificial intelligence.  And as a consequence, we lead in diagnosis and image-guided therapy, patient monitoring, clinical informatics, and personal care and personal health solutions.  These innovations do not come about because we have people living in labs.  They come about because we partner with university hospitals, with academia like MIT, Stanford, Texas A&M University System.  And also with many startups.

And we believe that the word “co-creation” is essential.  Open innovation is very essential.  Nobody can solve all the world’s challenges on their own and claim ownership; these systems are far too complex.  We need to join hands, lock arms, stand shoulder to shoulder, in order to deliver a healthcare system that drives better outcomes for everybody.

So, I have given you five words: outcomes, inclusion, productivity, seamless care, and I believe that is founded on great innovation that is done by all of us, together.  Innovation is driven by people, the creativity that is in everybody, the insights that a lot of people can contribute.  And because we bring it together, we can come to breakthrough solutions.  Solutions that then get adopted.  Because how many innovations stay on the shelf but never get adopted because we didn’t do the proper change management with the people involved?  Taking along the doctors and the nurses and the care providers and the payers.  And actually the consumers, the patients.

So I do believe that innovation as an inclusive approach to making technology work is essential.  It’s also why I’m thankful for The Washington Post for hosting the dialogue today and giving us an opportunity to interact and because we are all committed to making a better world with people that will have better lives.  Thank you.