Winter is Coming
The phrase “elephant in the room” does not do the coming healthcare storm justice, with most of the developed world facing an unsustainable crisis over the next 30 years.
It’s particularly bad in the US, where the combination of rising costs & underfunded pensions threaten to bankrupt the nation:
And it’s nothing but grey skies ahead...
The Silver Tsunami
For every single kidney dialysis patient they have, they need 3800 healthy lives to cover it. - Jim Chanos, quoting Blue Cross of California
Covid has laid bare the fragility of health systems globally, particularly as it relates to senior citizens.
Incompetent bureaucrats effectively staged a genocide against old people, with more than 40% of covid related deaths in the U.S. happening in long term care facilities, and you can go ahead and double that number(!) for Canada (note: those articles are somewhat dated).
And guess what?
The problem is only going to get worse, as seniors are both the largest AND fastest growing demographic globally,
That’s not how pyramids work….
Left unchecked, the health demands of the geriatric cohort will subsume the entire economy, bankrupting your children’s children.
Stan Druckenmiller even did a TED Talk, urging seniors to Please Dear God Think of The Children!:
And when hedge fund managers start protesting, you KNOW the problem is real.
An Ounce of Prevention
Necessity is the mother of invention - English Proverb
Preventative medicine is the obvious solution, and aligning incentives is the principal economic & political challenge of the next two decades…
But I don’t see how it gets done through existing channels.
Everywhere you look, the healthcare cartel is enormously powerful: in the US, big pharma, health insurance, hospitals and health professionals collectively represent $630mm in annual lobbying dollars.
(For context, the securities and investment lobby looks positively beggardly by comparison, donating a paltry 97mm)
The medical community effectively draws its own law and - doctor or no doctor - when people can legislate themselves money, they will.
Change is going to take an outsider.
Be Nice to Nerds
This is the computer Bill Gates and Paul Allen used to launch Microsoft, way back in 1974. At the time, it was still sold as a kit for hobbyists
If you want to get an idea of where the world is headed, look to the rebel rockstars of intellect, those high-iq, high-intensity misfits and drop-outs.
And right now, those very special souls are focused on biohacking.
The ODIN DIY Genetic Engineering Home Lab Kit
The genetic manipulation community today is not that far ahead of where Gates & Allen were in ‘74 - it’s still dominated by freaks, weirdos, and mad scientists.
Like this guy:
Josiah Zayner, the CEO of ODIN and the first person to perform a self-fecal transplant, in the hotel room(?!) pictured above.
(NSFL warning: this is even worse than it sounds)
The purpose? To reengineer his microbiome and permanently cure his irritable bowel syndrome.
And apparently, it worked!
Who needs a lifetime of dirty-bomb-style pharmaceuticals when you can take a laser-guided approach, identify what has been bothering you, and fix it once and for all?
Less-insane-but-no-less-curious folks have used more moderate methods, applying creativity via off-the-shelf medical devices, like non-diabetics using glucose monitors - such as the Abbott Freestyle Libre pictured below - to learn how their body reacts to different food types, and coming away with very interesting personal learnings (i.e. salad causes a greater insulin spike than vanilla ice cream in some people).
Imagination is more important than knowledge, for knowledge is limited, whereas imagination embraces the entire world, stimulating progress, giving birth to evolution - Albert Einstein
All the best people I know have been shifting over to med/biotech (shout out to my good friends and amazing founding team at SeamlessMD, and WSO’s very own @Techbanking!) and the coronavirus pandemic has only accelerated that trend.
Follow The Leader
One conversation centered on the ever accelerating progress of technology and changes in the mode of human life, which gives the appearance of approaching some essential singularity in the history of the race beyond which human affairs, as we know them, could not continue - Stanislaw Ulam, on speaking with uber genius John Von Neumann
And where the talent goes, the money flows!
The smartest VC’s have all been moving away from pure software plays, including big names like:
- Peter Thiel, who recently invested in a psychedelic drug startup
- Steve Jurvetson, who last April put money into a company that is “building a surrogate human immune system” (however that might work :s)
- Chamath Palihaptiya, who in his 2018 annual letter said the time is now for computational biology
And if you think VC’s are dumb herd animals, check out the last standing OG tech titans of yesteryear, Bill Gates & Larry Ellison.
Both have been devoting an increasing amount of their time to bio initiatives, with Gates leaving MSFT’s board to focus on global health and Ellison transforming the island of Lanai into his very own personal wellness laboratory (side note: has anyone here been to his recently renovated Lanai hotel? It looks absolutely wondrous).
And this is just the beginning!
Life Springs Eternal
Down the Street
and over the Wall,
an Oasis lies
ours to call (see what I did there?)
Great engineers look for grand problems, and there is nothing grander than “solving” death.
I’m not a life sciences guy, but people in the know tell me that ageing for a human is no different than ageing for a car - you can refresh, repair, and replace old/defective parts…
Or better yet, UPGRADE!
The young man in the picture above lost his hand in a workplace accident, and feared he would never play drums again..
That is until he connected with musician and inventor Gil Weinberg at Georgia Tech, who worked with him to develop a new bionic hand, capable of using two drumsticks at once - each with alternating frequencies - and enabling the creation of music no unenhanced human can produce.
I think the biggest innovations of the twenty-first century will be the intersection of biology and technology. A new era is beginning - Steve Jobs
As Moore's law continues unabated, once-impossible problems become trivial.
Humanity has begun transcending its biological roots, merging with its technology, and taking a direct role in designing its evolution.
Imagine a world where people age in reverse - growing stronger & healthier as time marches on - and human life expectancy is measured in thousands or millions of years.
What choices would you make when the consequences will be with you for millenia?
What kind of life would you lead when you could be reasonably confident that tomorrow will always be better than today?
The Final Word
When there is this much money and power up for grabs, you know “they” won’t leave it up to hackers and home brew hobbyists.
The coming revolution has already captured government attention, and for good reason: smallpox is estimated to have killed 500 million people before it was eradicated, and in 2017, a biotech firm you’ve never heard of synthesized a horsepox virus for $100,000.
Moore’s Law of Mad Science: Every eighteen months, the minimum IQ necessary to destroy the world drops by 1 point - Eliezer Yudkowsky
All signs point to a huge push for socialized medicine in the United States, with a massive increase in medical tourism for the rich.
(Spoiler Alert: my country has socialized medicine, and it’s better in some ways i.e. my father had a heart attack, and the total bill for triple bypass surgery and a month long stay in the hospital was $70 - and worse in others i.e. it can be a many months wait to see a specialist for non-urgent care, and our tech is last gen at best)
Do we have any IP attorney’s with a background in computational biology on the forum?
I would love to get your take on how the business of healthcare unfolds over the next 20-30 years.
What an exciting time to be alive!
Best,
CC
sheperd99 faceslappingcompilation GoingToBeAnMD @PteroGonzalez" Mostly Random Dude tengleha @cdrectenwald" BullingandBearing @laxskil" Dillingo AspiringIdiot @straighttohellxo" dsch kuf135 princepieman cayusbonus Njabulo Vincent-Hadebe thebrofessor Excelling TechBanking DickFuld Pump and Dump Jacqueline-Gallardo GreenspanAndHam urmaaam Synergy_or_Syzygy DeepLearning Este5 UTDFinanceGuy @Pio nono" Shadow_Tenderfoot @crookedhillary @Layne Staley" thexfactor336 BBDreamin Disjoint anoss watdo monkeyseemonkeypoo @LReed" Secyh62 KLMC Dig Bumb Idiot @real_Skankhunt42" wannabetrader11 sl55amg Pmc2ghy the_gekko LeveragedTiger iridescent007 hungry23 More Leverage accountingbyday Whiskey5 Sham Wow man-1500 WolfofWSO AlexCook MonacoMonkey @TNA" GoodBread APAE Port Ricky Pass the Mayo oligarch @Billions with a B"
The Youtube Videos aren't displaying properly so here are the links:
watch?v=GgTwa3CPrIE
watch?v=KscnT6FxMIQ
watch?v=GgTwa3CPrIE
Are those links? They aren't playing for me... if I copy/past from the equal sign "KscnT6FxMIQ" and search, the top hit in Google is "Becoming immortal | VPRO documentary" which I assume is what was supposed to be linked. Also, the first and third links you posted appear to be the same, "Beyond bionics: how the future of prosthetics is redefining humanity"
PM'd you the YouTube links (there are actually 4)
delete
appreciate the tag, I always love your long form posts, I just am uneducated on healthcare from an industry perspective, and part of this is my own stubbornness. I have a hard time thinking innovation is gonna save the world when over 70% of the US is overweight or obese. sure, I believe that innovation will continue and will produce some really cool stuff, I'm optimistic on the mental health front in particular, but I see more hypocrisy than upside in making a type 2 diabetes therapy that costs millions or billions to make when the best type 2 cure ever is already there - put down the fork and go for a brisk walk.
/rant
So Bill Gates believes that in the not too distant future, we'll solve the obesity epidemic by reprogramming the microbiome, which apparently controls appetite.
Ray Kurzweil thinks pharmaceuticals are the answer; they will allow us to turn off the fat storage mechanism in the human body.
maybe I'm too skeptical and jaded, I fail to see how technology can fix lack of discipline and ownership of one's health. if you take an obese person who's lazy and something controls their appetite but they're still drinking HFCS stuffed sodas and processed sugary garbage, sure they may lose a couple of pounds, but if they're still insulin resistant they're fucked. and even if this pill makes them insulin sensitive, how long will it last? what about other side effects that we don't have a clue about?
I don't doubt the microbiome plays a part, but I worry about unknowable side effects. there are potentially huge downsides with tinkering on the human body at a population level, there's very little downside to eating the right stuff and breaking a sweat regularly. but then again, that's not profitable so no one is throwing money at the most reliable way to improve one's health - with lifestyle choices.
I think you just have a bone to pick with fat people ;)
I have compassion for all, but I lack patience for those who lack discipline
How do you reconcile your view that people are fat because they "lack discipline" with the loads of adoption/twin data that show that obesity is almost as heritable as height? Are people short because they lack the discipline to grow taller? Alternatively, is lack of discipline itself a heritable trait (and if so, how does it make sense to blame people for it any more than for their height or baldness?)
And before you say "people used to be thin": people used to be shorter, too. Even so, height is heritable, and people have very little influence over how tall they grow. The average height difference between people in 1800 and 2020 is the result of widespread environmental factors that can't be changed by any individual person.
if discipline and obesity were as heritable as height, I would not be in shape nor would I be disciplined.
there's also evidence that habit formation can change your genes, therefore change what can be passed down. ergo, there's some things within your control.
I feel like you've shared this counterpoint before, so I'll give you the same response - let's say what you're saying is true. does that mean it is not worth the effort to attempt to become disciplined? I argue no. I am an example of this. my parents are fat and undisciplined, ditto for their parents, I am the opposite. so whatever was passed down to me has clearly been changed, and while one exception does not make it a statistically significant finding, I'll repeat it again - if it could possible, why not try?
finally, as I said to OP below, there are plenty of people who despite ridiculous discipline still have flab (anyone who just watched the gastelum fight this weekend knows what I'm talking about, he's carrying some extra body fat but is insanely disciplined). in those cases, either become the best endomorph you can be, or rely on medical interventions if you're still having problems. I never said my issue was with people who are overweight despite discipline due to environmental/biological factors, I said "undisciplined pantloads," which I feel is the vast majority of the 73% of Americans who are overweight/obese.
if there are data to the contrary, I am happy to change my mind.
Ok, here's some data:
https://www.frontiersin.org/files/Articles/17732/fendo-03-00029-HTML/image_m/fendo-03-00029-t001.jpg
This is from a peer-reviewed medical journal paper that analyzes the results of 31 separate twin studies of BMI heritability, with a total sample size of more than 140,000 people. The mean BMI heritability they find is 0.75. For comparison, similar studies on first-world populations often find height heritability of 0.8 or 0.9.
Other studies that compare the BMIs of adoptees to those of their adoptive parents find virtually no correlation. In other words, parenting has no impact on how fat or thin people become as adults. The reason that thin parents tend to have thin biological kids, which they do, is genetics.
I also think you're framing this question in the wrong way, i.e. "people who are overweight...due to environmental/biological factors" versus "undisciplined pantloads". Presumably "biological factors" for you means something like abnormally slow metabolisms or unusual gene mutations, whereas "undisciplined" means consistent overeating in otherwise normal people.
But it's precisely the tendency to overeat that the biological factors-the genes-mainly influence. People with certain genetic makeups, when placed in environments loaded with cheap, highly-engineered processed foods, have an extremely difficult time controlling their appetites over the long term. But they would have no problem in environments that lacked these foods. Alcoholism also has a significant genetic component, but people with no access to alcohol don't become alcoholics.
The view that I'm presenting here is the view of most of the top scientists and specialist doctors who devote their careers to this topic. It just hasn't percolated out into the general public very well.
I do not believe BMI is a relevant data point. it does not tell you anything about insulin resistance or body fat percentage.
from the NIH: The BMI has been useful in population-based studies by virtue of its wide acceptance in defining specific categories of body mass as a health issue. However, it is increasingly clear that BMI is a rather poor indicator of percent of body fat
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890841/#:~:text=The%20BMI….
on undisciplined, I mean people who do not have consistent healthy eating and exercise habits. as in you lack the discipline to not buy sugary foods and drinks in the store, you lack the discipline to exercise daily, you lack the discipline to not hit the bottle every night, you lack the discipline to stop eating when you're 80% full. if what you're saying is true, I would not look the way I look nor have the bloodwork I do. I grew up in the south around highly processed foods, people who never exercised, parents who never bought healthy food, and quite a long line of alcoholism. while one exception does not make a rule, it does refute the idea that one should just accept that these traits are inheritable and therefore not reversible.
in closing, as this is the 2nd time we've gotten into this discussion and I've learned nothing and I don't seem to be getting across to you, I bid you farewell. other readers can parse our arguments if they wish, but this will be the last reply I make to you on this subject. I hope you have a happy and healthy life, take care.
And as to your "what is the point of talking about this" question: the point is to give people a more accurate understanding of reality.
Your theory seems to be that if we frequently ridicule fat people and downplay the science I discussed, some of them may, with intense willpower, end up somewhat less fat than they would be otherwise. At least for a while. I'm not sure how well-supported that idea is- maybe you have some evidence.
Personally, I'm not a big fan of noble lies. It's more likely that we'll solve this problem if more people actually understand what's going on. And the solution, if any, is going to come from a population-wide intervention. Not from lectures about personal discipline.
Metformin already exists and they still progress to type 2 diabetes. You can’t fix lack of discipline and fucked dopamine systems. Think of all of the people who get gastric sleeves and then eat themselves to death. Even most of the non-obese people I know are thin because of adderall or coke all weekend long, not because they actually work on their health
And things are only going to get worse since people are addicted to the internet and instant gratification like 1-click shipping, etc.
Yup. Americans are obese and immobile, in addition to being self indulgent as all fuck - alcohol, smoking, drugs, looking for band aids or lazy ways out instead of addressing the root problem.
Eg, I do low carb IF but wtf some of these people are inhaling deep fried cream cheese drizzled in ranch and 1 lb of bacon in one sitting because they can still technically lose weight while not having to work out. Seriously wtf is wrong with people and I feel that this kind of shit is strictly a US/UK mentality
The US healthcare system is broken, yes, but look at the people that it serves. It is rarely fit and mindful people who are complaining about healthcare costs, I’ll tell you that
amen brother. if only people listened to the CDC's recommendations on diet & exercise like they do with Covid stuff, we'd be in a better place as a country.
Agree.
But... we're supposed to exercise and eat properly, but many don't, to their own detriment. Pound cure, ounce prevention, etc. So, you could follow that line of thinking into future / biohacking world where we basically just upgrade and/or swap out shitty parts of our physiology as issues arise. No reason to stop being a smoker if you can just get new lungs. New ears if you get tinnitus. New _____ once you've abused and exceeded the biological limit of some artery/limb/synapse.
fine by me, to each his own. doesn't mean I have to abide, also doesn't mean I have to stop stating harsh truths about undisciplined pantloads (which I will continue to do).
Ok so let me ask you this.
I was at one time a competitive athlete, and extraordinarily disciplined - 2 or some times 3 a day workouts, weighing my food, regular blood testing, etc.
But no matter how hard I worked, there were guys I competed against that would absolutely destroy me, despite terrible diets, undisciplined training regimens, party lifestyles, etc.
From an athletic perspective, they were simply superior to me genetically - higher natural testosterone levels, more fast twitch muscle fibers, whatever - and no amount of hard work would ever compensate for that.
Would you agree that for many people (not all) weight control might be more complicated than "putting down the fork and going for a brisk walk?" What's wrong with a chemical/biological intervention if it saves lives? Weight gain is the most common side effect of prescription medication, and given that 66% of all adults in the US use prescription meds, would you agree that for some of them (again, not all) body fat percentage is beyond their control?
like all things, there are exceptions, and I'd bet you are a rare exception. what I'm saying is a platitude that is arguably true for most, not for all. I'm 100% for medical interventions, I just think they should be a last resort after you've tried lifestyle interventions. people go for a pill before they go for the gym. you did not do this, are still experiencing issues, and likely your biology needs something medical to tip the scales (literally and figuratively).
so yes, I would agree, for many people it's complicated, but for most people I'd argue it's simple.
Well done as always, love these posts. WSO needs more of this type of content vs the millionth post from a freshman asking if they can make 8 figures at a hedge fund.
I’m not too educated on the health care space overall, but I do think that the aging populations of developed nations and improving quality of care in emerging markets through investment as those populations grow are major secular themes for the foreseeable future. As a result, half of my PA is health care tech that I can understand (won’t invest in pharma or bio given my lack of knowledge).
Health care has always struck me as having and odd relationship with capitalist economics and incentives. The most profitable solutions are to keep your customers alive, but just barely. The PV of cash flows is truncated when you actually provide a cure. At the same time though, nothing provides stronger incentives to develop new technology, drugs, and innovations like capitalist payoffs. So there needs to be a balance, and a better balance than what we have currently achieved in the U.S. with egregious pricing. I’ve also always thought that patent lives were too long, likely a result of the massive lobbying effort that you cited, and part of the reason why health care costs are what they are. If patent lives were shorter it would drive more competition and force companies to be more innovative while lowering barriers to entry. I’m not saying eliminate patents, but the current patent lives essentially legalize product and/or category monopolies. As a result, you get abusive pricing with competition eliminated for as long as 20 years. I get it, sometimes the research effort to develop a drug in the first place can take a decade. I don’t know what the right number is or if there is a better alternative, this is outside of my core competencies, so maybe someone with more direct health care exposure/experience can comment on whether patent lives contribute to our issues. Just thinking out loud.
Or how to get into a tiger cub / activism fund
Yeah healthcare incentives are super tricky.
Steve Jurvetson thinks there might be a way to get costs down to ZERO:
https://www.facebook.com/jurvetson/posts/10154273762285611
This is great content. Please keep posting. Hey AndyLouis , how do we get more of this?
I would give more SBs if I could.
Thanks man!
I really appreciate it.
+1 WallStreetOasis.com
Wow, was not expecting a read like this on WSO today. Great post, thanks for the time and effort. I'd comment about it but I actually need to think on this stuff for a bit rather than just run my mouth :)
Thanks! Yeah hopefully a change from the doom and gloom of WFH banking...
Surprised you didn't touch on gene editing at all. Not just somatic gene editing to cure things like Sickle Cell but germline editing to eventually completely eradicate genetic diseases or even alter predispositions towards disease (e.g., reduce risk of hypertension).
Just read the new Walter Isaacson book on Jennifer Doudna and genomics (and there's a whole host of interesting ethical considerations here too), but seems like this could be a new era of health solutions.
I don't have the requisite scientific background to speak intelligently about gene editing, and it would have been a LOT of work to get up to speed.
In the short and medium terms, gene editing will probably be amazingly helpful to a small number of people who have diseases caused by single loci in their genomes. Polygenic conditions are more common but will be much more difficult to treat with gene editing- for now, anyway.
A likely alternative is GWAS + genome sequencing + IVF. First, genome studies find statistical correlations between gene variants and physical traits. This allows for the calculation of "polygenic risk scores" for individuals based on their particular genomes. Next, people do IVF and create a few embryos. Then they sequence each of the embryo genomes, find the "best" one, and implant it. Then the mother carries the pregnancy to term.
Right now, the number of embryos that can be produced by IVF is constrained by the number of eggs the woman can produce. But this really gets crazy when you add eggs produced by pluripotent stem cells. Then you could do huge numbers of embryos and pick the extreme outliers. This would fundamentally transform humanity.
We're not that far away from this world. Much of the technology exists now, although some of it has only been used on animals. It just needs to be refined and the cost needs to be reduced.
What good is technology in a system in like the US where most people won't be able to afford it and insurance won't cover the technologicaly advanced treatments that are coming? Greed and bad policy has de-stabalized the medical system and we can't realy on it being improved by technological advances.
The best way to improve society's health would be to ban all foods that didn't exist in the year 1900. This would be a far cheaper and more powerful intervention than anything the healthcare industry could produce.
Good luck with that plan!
I wish. A more realistic possibility is that there will be some kind of pharma semi-solution. There's a class of drugs called GLP-1 receptor agonists that look promising. But Doritos and Big Macs are the real problem.
Hey, this is exactly what my fund does! We’ve got an IP lawyer with a genetics ph.d that I’m sure would love this thread but there’s no way he’s on WSO lol
Any chance he would make an appearance to enlighten us?
Very unlikely I can get him on here but feel free to DM me if you ever have a question, happy to send it over
No healthcare expertise here unfortunately but love the long term mentality and well thought out explanations. Very interested in infrastructure/energy myself for many of the same thematic reasons, as I feel like they’ll become much more important/valuable in coming decades.
Thank you.
I have a bit of a problem with this ideas - it's an old obession with extremely wealthy people to live forever, and freezing a dead body to be potentially revived in the future is not a new idea (once the "science" catches up). There is that very arrogant writer who talks about that in homodeus. I personally think this obsession with living forever in your current body is quite unhealthy - as a Christian you get ready for the after life, live a good life on earth and get ready to leave it.
Replacing parts of the body as they age like an old car, sure. There is clearly some good research going into all of this, with the most useful helping people that have lost limbs be able to function again. At the moment there is a lot of faff, as always, from startups and companies trying to raise money by claiming the impossible. I am just not that excited about it.
Tell you one thing that excites me, and in which I've poured money into: nuclear energy and maybe fake protein, I did that.
Not very insightful what I wrote, but it's Sunday and I have a thumping headache.
I mean, it's not just super wealthy people.
Sean Carroll is on record saying that in the not too distant future, technology will allow humans to live for millions of years.
And yes, Yuval Noah Harari of Homodeus is beyond arrogant.
Thanks for sharing!
For anyone interested in learning more about healthcare in terms of future growth/synergy targets, great place to start:
https://www.bain.com/globalassets/noindex/2021/bain_report_global_healt…;
Have we ended evolution now that the majority of people survive and can breed? Is taking the direction of humanity into our hands the right thing, the end of evolution, or is this the end of humanity?
As a side note and tangentially related, birth rates in developed nations are falling like a rock (as is marriage), what do falling birth rates and evolution have in common: the demise of the human race. Sperm counts and testosterone have been falling every year (1-2%) for the last 100 years... and if we continue on this trajectory, sperm counts will fall to zero in about 50 years (they say at that time men won't have enough testosterone to get an erection): https://www.gq.com/story/sperm-count-zero
Spot on. This is the most likely outcome of the next 100+ years and the possible death knell of the human animal, in my opinion. Humanity has been up its own ass about how smart and important it is for millennia, yet we seem to be actively fucking with evolution and positioning ourselves for catastrophic failure as a species.
Honestly, maybe that is evolution at work. Perhaps the removal of humanity or reduction to prehistoric population levels is all part of evolutionary equilibria on a grander (global) scale. We thrive, proliferate, attempt to concur nature and design our own evolutionary path forward, fail catastrophically, and reboot back near the bottom rung. With techno-futurists going on about living forever and synching the human brain with AI, it's actually kind of hilarious to think that a lack of birthrate (driven by our ambition/stupidity/tinkering with evolution) could kill our species off within a couple generations.
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