I first became aware of Casey Quinlan in 2017, when she published an article in Tincture, which I was helping to edit. In it, she discussed how she’d had her medical history and advance directive tattooed on her chest, out of frustration with the lack of health information exchange in healthcare. As she said, “ALL. THOSE. FUCKING. FORMS. ON. CLIPBOARDS.”
Well, I thought: she sounds like an interesting person.
I started following her on Twitter, enjoying her outspokenness and agreeing with many of her points of view. Then early in the pandemic Matthew Holt started THCB Gang podcast, and I got to participate in many of them with her as a co-panelist. It was sometimes hard to get a word in edgewise, but when she was on we always knew it was going to be an extra-lively session. And the stories she could tell…
I never met Casey IRL. I never worked with her. I never even had a one-on-one conversation with her, unless you count Twitter replies. There are large parts of her life that I don’t know anything about. But, boy, the force of her personality, the strength of her will, the sharpness of her intellect, and the fearlessness of her personality were always clear.
She fought her cancer as fiercely as she lived her life generally. We knew the end was inevitable, but it nonetheless was hard to imagine. There have been outpourings of support on Twitter, on CaringBridge, and elsewhere. I have to mention in particular the efforts of Jan Oldenburg, who was there with her near the end and also took on the various bureaucracies on Casey’s behalf when Casey was no longer able to.
Casey’s passing is a loss to her friends, her followers, and the patient community at large. And to those of us who got to know her even a little bit.
Chances are, you’ve read about AI lately. Maybe you’ve actually even tried DALL-E or ChatGPT, maybe even GPT-4. Perhaps you can use the term Large Language Model (LLM) with some degree of confidence. But chances are also good that you haven’t heard of “liquid neural networks,” and don’t get the worm reference above.
That’s the thing about artificial intelligence: it’s evolving faster than we are. Whatever you think you know is already probably out-of-date.
Liquid neural networks were first introduced in 2020. The authors wrote: “We introduce a new class of time-continuous recurrent neural network models.” They based the networks on the brain of a tiny roundworm, Caenorhabditis elegans. The goal was networks that were more adaptable, that could change “on the fly” and would adapt to unfamiliar circumstances.
Researchers at MIT’s CSAIL have shown some significant progress. A new paper in Science Robotics discussed how they created “robust flight navigation agents” using liquid neural networks to autonomously pilot drones. They claim that these networks are “causal and adapt to changing conditions,” and that their “experiments showed that this level of robustness in decision-making is exclusive to liquid networks.”
An MIT press release notes: “deep learning systems struggle with capturing causality, frequently over-fitting their training data and failing to adapt to new environments or changing conditions…Unlike traditional neural networks that only learn during the training phase, the liquid neural net’s parameters can change over time, making them not only interpretable, but more resilient to unexpected or noisy data.”
“We wanted to model the dynamics of neurons, how they perform, how they release information, one neuron to another, Ramin Hasani, a research affiliate at MIT and one of the co-authors, told Popular Science.
Essentially, they trained the neural network to pilot the drone to find a red camping chair, then moved the chair to a variety of environments, in different lightening conditions, at different times of year, and at different distances to see if the drone could still find the chair. “The primary conceptual motivation of our work,” the authors wrote, “was not causality in the abstract; it was instead task understanding, that is, to evaluate whether a neural model understands the task given from high-dimensional unlabeled offline data.”
Daniela Rus, CSAIL director and one of the co-authors, said: “Our experiments demonstrate that we can effectively teach a drone to locate an object in a forest during summer, and then deploy the model in winter, with vastly different surroundings, or even in urban settings, with varied tasks such as seeking and following.”
Essentially, Dr. Hasani says, “they can generalize to situations that they have never seen.” The liquid neural nets can also “dynamically capture the true cause-and-effect of their given task,” the authors wrote. This is “the key to liquid networks’ robust performance under distribution shifts.”
The key advantage of liquid neural networks is their adaptability; the neurons behave more like the worm’s (or the neurons of other living creatures) would, responding to real world circumstances in real time. “They’re able to change their underlying equations based on the input they observe,” Dr. Rus told Quanta Magazine.
Dr. Rus further noted: “We are thrilled by the immense potential of our learning-based control approach for robots, as it lays the groundwork for solving problems that arise when training in one environment and deploying in a completely distinct environment without additional training…These flexible algorithms could one day aid in decision-making based on data streams that change over time, such as medical diagnosis and autonomous driving applications.”
Sriram Sankaranarayanan, a computer scientist at the University of Colorado, was impressed, telling Quanta Magazine: “The main contribution here is that stability and other nice properties are baked into these systems by their sheer structure…They are complex enough to allow interesting things to happen, but not so complex as to lead to chaotic behavior.”
Alessio Lomuscio, professor of AI safety in the Department of Computing at Imperial College London, was also impressed, telling MIT:
Robust learning and performance in out-of-distribution tasks and scenarios are some of the key problems that machine learning and autonomous robotic systems have to conquer to make further inroads in society-critical applications. In this context, the performance of liquid neural networks, a novel brain-inspired paradigm developed by the authors at MIT, reported in this study is remarkable. If these results are confirmed in other experiments, the paradigm here developed will contribute to making AI and robotic systems more reliable, robust, and efficient.
It’s easy enough to imagine lots of drone applications where these could prove important, with autonomous driving another logical use. But the MIT team is looking more broadly. “The results in this paper open the door to the possibility of certifying machine learning solutions for safety critical systems,” Dr. Rus says. With all the discussion about the importance of ensuring that AI was giving valid answers in healthcare uses, as noted above, she specifically mentioned medical diagnosis decision making as one for liquid neural networks.
“Everything that we do as a robotics and machine learning lab is [for] all-around safety and deployment of AI in a safe and ethical way in our society, and we really want to stick to this mission and vision that we have,” Dr. Hasani says. We should hope that other AI labs feel the same.
Healthcare, like most parts of our economy, is going to increasingly use and even rely on AI. We’re going to need AI that not only gives us accurate answers but also can adapt to quickly changing conditions, rather than pre-set data models. I don’t know if it’s going to be based on liquid neural networks or something else, but we’re going to want not just adaptability but also safety and ethics baked in.
Last month I wrote about Organoid Intelligence (OI), which intends to gets to AI using structures that world more like our brains. Now liquid neural networks based on worms’ brains. It’s intriguing to me that after several decades of working on, and perhaps for, our silicon overlords, we’re starting to move to more biological approaches.
As Sayan Mitra, a computer scientist at the University of Illinois, Urbana-Champaign, told Quanta Magazine: “In a way, it’s kind of poetic, showing that this research may be coming full circle. Neural networks are developing to the point that the very ideas we’ve drawn from nature may soon help us understand nature better.”
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
Casey Quinlan, our friend and frequent TCHB Gang member, died today. She may have gone quietly but she for sure lived her life way out loud. It’s not unexpected; she was diagnosed with a recurrent stage 4 cancer two years back, and I was lucky enough to have dinner with her on a rare east coast trip last June. She was hoping to come to the West Coast late last Fall but was too sick to make it. It looked like things were getting better and she was on THCBGang in February but soon things turned and she spent the last few weeks in hospice. She leaves a huge hole in the patient advocacy movement and a huge wave of love from her friends today on Twitter. And she remains the only person who has come up to me after I gave a talk and shared a shot of bourbon from her hip flask at 9 am! The talk was about the US health care system. So we both needed it! We’ll miss you Casey… Matthew Holt
Ines Vigil, SVP Transformation & Services, Clarify Health Solutions talked with me at HIMSS23. A quick discussion about what Clarify Health does, and why the health system needs a huge database of 330m patients. Quick clue is that payment negotiations and benchmarking of clinical performance is the biggest demand, and Ines now actually heads up a consulting group that providers need to be overlaid on that data–Matthew Holt
Live and in-person once again, HIMSS 2023 attracted more than 30,000 attendees to the exhibit halls and meeting rooms of Chicago’s sprawling McCormick Place. Although no one person could possibly absorb it all, below are some harbingers of the health care future that stayed with me.
Size Doesn’t Count. Exploring the remote byways of the cavernous exhibition areas, it became clear that it’s not the size of the booth, but the impact of the product that counts. At a pavilion highlighting Turkish companies, for instance, R. Serdar Gemici stood in front of a kiosk that might fit into a walk-in closet.
The display listed an impressive roster of clients for a chronic care management platform, prompting me to stop to learn more. The smartphone user interface for “Albert,” the namesake product of Albert Health, the company Gemici co-founded and leads, immediately impressed me as one of the simplest and yet comprehensive I’d seen. (Indeed, the company website boasts of the “world’s simplest health assistant.”) Albert Health has begun working with England’s National Health Service and large pharmaceutical companies, though I found myself wondering how the name resonates in the Turkish- and Arabic-language versions the company touts.
HIMSSanity 2023! (Photo:HIMSS)
Another far-off cluster of kiosks hosted a company called Dedalus, which promised an interoperable, whole-person care platform. A demo included a graphic showing a breadth of holistic personalization and collaboration capabilities I’d not seen elsewhere. It turns out that while Dedalus only entered the U.S. market in late 2021 – which explains why, as the nice woman showing me the presentation noted, Americans mostly haven’t heard of it – Italy-based Dedalus Global’s software and services are used in more than 40 countries by over 6,700 health care organizations.
Oh.
Size Does Count. When I sat down with Dr. Jackie Gerhart, Epic’s vice president of informatics, and Seth Hain, senior vice president of research and development, at their very large and very busy booth, I had in mind Epic CEO and founder Judy Faulkner’s reputation as a tough, my-way-or-the-highway businesswoman. But Gerhart and Hain were so nice and down-to-earth, earnestly extolling the company’s culture of collaboration, that it was initially as disorienting as watching Elon Musk help a little old lady across the street. (A colleague assured me that, yes, this is actually the way many Epic employees act.)
Nonetheless, Epic remains a 500-pound gorilla, with a third of the hospital electronic health record (EHR) market. Its Cosmos platform, containing records from over 184 million patients and 7 billion encounters in all 50 states, is the largest integrated database of clinical information in the nation. The company is currently working to integrate Microsoft’s ChatGPT generative AI with Cosmos’s data visualization capabilities, which presents fascinating possibilities.
Ask around, though, and you’ll discover that not all hospitals are comfortable with Epic’s control of information. There will certainly be competitors, perhaps including the Mayo Clinic Platform.
A colleague related that many years ago big tech firms marketing their own EHRs warned prospective customers that choosing Epic meant relying on a company that might not be around very long. Instead, those competitors aren’t. Underestimating all those nice (and perhaps some not-so-nice) people at Epic would be a serious mistake.
Who’s Your Daddy? So, DeloreanAI, you appear to be just one more small vendor promising to apply predictive analytics to help prevent and treat chronic disease. And you, Medeanalytics, at a neighboring kiosk in the Innovation Pavilion, how do you expect your revenue cycle management product to compete with the big guys? Wait – you’ve both got Optum (2022 revenues: $183 billion) “white labeling” your technology? Never mind.
Digital Health Has a Johnny Appleseed. “Johnny Appleseed” (the nickname of John Chapman) famously planted apple trees across the American frontier. Israel’s Eyal Zimlichman, a physician and researcher, is doing much the same globally with ARC (Accelerate, Redesign and Collaborate), the center for digital innovation he launched at Sheba Medical Center in 2019. ARC brings together top-tier medical centers (like Mayo and Mass General Brigham in the U.S.), researchers, start-ups, investors and established companies from 16 different countries to plant the seeds that allow health system redesign to grow and flourish. ARC affiliates have been responsible for a total of 179 patents and 221 trade licenses.
Zimlichman, who heads ARC and also oversees Sheba’s innovation and transformation efforts, presented to a HIMSS forum on quality and patient safety, topics close to my heart. (Disclosure: In 2013, I co-authored an academic paper with Zimlichman.) He spoke about artificial intelligence (AI) advances enabling real-time clinical decision support during surgery; sensitive alerts to prevent medication errors and falls; and reducing deaths from intracranial surgery.
ARC wants to establish a “Future of Health” community that will “impact the course of global health through shared belief and collective wisdom,” Zimlichman said.
As the Yiddish expression goes, “From your mouth to God’s ears.”
People to Watch (1). Jean Druin, MD, MBA, founder and chief executive officer of Clarify Health, volunteered to help out in Nelson Mandela’s South Africa straight out of college and, while still in his early 30s, helped redesign England’s National Health Service as head of strategy for NHS London. As befits that background, Druin believes that building and automating effective processes provides the foundation for improving health care outcomes. A quality improvement culture, he told me, “always emanates from having strong underlying processes and systems that enable them.” To help organizations operating in a value-based care environment make that happen, Clarify’s platform provides access to data covering over 4 billion patient care journeys.
People to Watch (2). The National Committee for Quality Assurance, better known as just NCQA, is an independent nonprofit firmly ensconced in the Washington policy community. But Dr. Bradley Ryan, NCQA’s first chief product officer, comes from a very different world, having worked for McKinsey and IMS Health and co-founded a health tech company. Ryan is frustrated by the persistence of poorly collected, non-standardized health data that obstruct efforts to make care better. (Many others are, too, as these experts recently vented.) “I’m passionate about the way we evolve quality improvement,” Ryan told me. His goal is to reinvent NCQA’s plan and provider measurement for the digital age in order to improve data accuracy, trustworthiness and usability.
People to Watch (3). Vibhor Gupta, a veteran oncologist and entrepreneur, presented at the Microsoft booth about his newest company, Pangaea. Pangaea applies AI to the unstructured data in physician notes in order to identify undiagnosed or miscoded patients having one or more of 4,000 “hard-to-diagnose” conditions, including complications of cancer. “More than 50 percent of codes are incorrect,” avers Gupta, before diving into why Pangaea’s unsupervised AI can dig out data conventional natural language processing cannot. The easy path, of course, is finding patients for drug company clinical trials, but when I speak to Gupta afterwards, it’s clear he’s equally committed to improving everyday patient care.
People to Watch (4). Before there was an Intermountain Healthcare, a physician informatics pioneer named Homer Warner developed digital patient monitoring systems at what was then Latter-Day Saints Hospital way back in the 1960s. I’d chronicled Warner’s achievements in my book, so naturally I was interested in talking to Mona Baset, Intermountain’s vice president of digital services. Baset came to health care from financial services, where a consumer orientation is imperative. “We need to get Intermountain to the point where it’s an amazing experience, and the experience is the advantage,” she told me. “Amazing” health care experiences? I’m skeptical, but perhaps with Baset we can bank on it.
People I Could Barely Watch. A HIMSS plenary session entitled, “Healthcare Disruption: Accelerated Opportunities for Care Delivery Alternatives” should have been an episode of the TV game show, To Tell the Truth, in which you have to guess which contestant’s story is true.
Was the real disrupter Andrea Walsh, chief executive officer of Minnesota-based HealthPartners, who declared, “Our commitment is to bring care to people where they are at”? Maybe.
Tim Barry (Photo: HIMSS)
Was the disrupter Deborah Di Sanzo, president of Best Buy Health? Trick question! Only if you think “care delivery” means physically delivering and setting up medical equipment. “We can make a difference in the plumbing role,” Di Sanzo insisted, while perhaps thinking to herself, “I used to run a division of IBM!”
Or was the disrupter Tim Barry, chairman and founder of VillageMD, who described the significant changes to the delivery of primary care his company has already implemented, as well as plans to spread its model to multi-specialty care?
“One of the things we have to acknowledge as a health care system,” he said, “is that not everyone can win.”
You mean disruption is disruptive? Barry’s the one telling the truth!
Technology Like Mom? I was due to a meet a colleague for lunch at a restaurant a few blocks from McCormick Place, but I wasn’t sure which exit in the massive complex would point me in the right direction. As I stood on the third floor of the central concourse, Google Maps had the answer: “Go down the staircase,” it directed me, with a map showing that I would then go out the door, cross the street and turn right.
Someday soon there could be an app whose detailed spoken directions include adding that I shouldn’t have waited until the last minute to leave for lunch, not to mention lamenting that I wasn’t dressed warmly enough given the temperature outside.
A month ago an oncologist called and asked me to see one of my heart failure patients whose chronically swollen legs seemed unusually blue but not cold.
Before I could get him in to see me, he ended up seeing a colleague, who called me up and said the man’s legs were cool and there was no Doppler in that office to check for pedal pulses. The man was sent for an urgent CT angiogram with runoff.
The test was perfectly normal. He had clean arteries.
When I saw him, the legs were less blue than they must have been and they felt OK but he had what looked like a shingles rash around his right elbow. There was some surrounding swelling and redness, so I prescribed an antiviral, an antibiotic and prednisone and arranged to see him back.
My diagnosis was erythrocyanosis. I have never seen a case but my instinct when I saw him was that this was a peripheral thermal regulation problem. So, a little bit of searching on the Internet gave me the diagnosis.
In follow up, the legs looked fine and the elbow rash was drying up nicely.
None of my research suggested a reasonable treatment option for his condition. But he was getting better so I didn’t have to worry about it at that moment.
A few weeks later I saw a young woman who spends her free time in a horse barn. She had a bluish discoloration of her outer thighs on both legs with some red spots scattered throughout the affected area. She told me she had had something similar a year or two earlier and her doctor had given her five days of prednisone. It took three weeks for her symptoms to clear up.
As soon as she had finished telling me her story and showing me her thighs, I was able to tell her what her problem was and I could also tell her that horseback riding is one of the triggers. In her case she was just spending time in the cold barn but the trigger mechanism behind the condition is exposure to cold under any circumstance.
I told her I had seen a case of her condition just a little while earlier and that that man ended up with what seemed like a case of shingles and I wasn’t completely sure if that was connected.
“Well, I got shingles just after I had that first episode“, she said.
“That’s very interesting, let me do some googling to see if there is a connection”, I said.
I didn’t come up with anything while I saw her but I promised to look into it more.
All that came up within my research was that erythrocyanosis, also called pernio, closely related to chilblains, can cause blisters or skin ulcers.
Not long after that my elderly man with erythrocyanosis was back. This time he had swelling on his right elbow with a lot of scabs and his forearm was cold and blue. I have a Doppler in my office, so it took me almost no time to walk down the hall and get it and establish that the systolic blood pressure in his right arm was 140.
There was obviously an infection going on so I prescribed an antibiotic again, I skipped the antiviral but I did prescribe prednisone in case that had done anything good for him last time. I promised him to call our dermatologist in the big city to ask if there was anything more they could do for him. He has a follow up on Monday.
This afternoon I got a return call from a dermatologist, offering a few hints and also offering to give this patient priority and get him in before the nine month wait they usually have for new patients (the reality in a physician shortage area).
Hans Duvefelt is a family physician, author, and creator of “A Country Doctor Writes”
Last year I used some of Alfred North Whitehead’s pithy quotations to talk about healthcare, starting with the provocative “It is the business of the future to be dangerous.” I want to revisit another of his quotations that I’d like to spend more time on: “The silly question is the first intimation of some totally new development.”
I can’t promise that I even have intimations of what the totally new developments are going to be, but if any industry lends itself to asking “silly” questions about it, it is healthcare. Hopefully I can at least spark some thought and discussion.
In no particular order:
Why do we prefer to spend money on care when people are no longer healthy than we do on keeping them healthy?
The U.S. healthcare system well known for being exorbitantly expensive while delivering rather mediocre results. Everyone laments it but we keep throwing more money into the system that is producing these results.
We’d be smarter to invest in upstream spending. Like making sure people get enough to eat, with foods that are good for us. We’d rather spend money on diabetes or obesity drugs rather than addressing the root causes of each disease. Or like making sure the water we drink, the air we breathe, the things we eat, aren’t polluted (how many toxins or microplastics have you ingested today?). Not to mention reducing poverty, improving education, or fixing social media.
We know the kinds of things we should do, we say we want to do them, but we lack the political will to achieve them and the infrastructure to ensure them. So we end up paying for our neglect through our ever-more expensive healthcare system. That’s silly.
Why is everything in healthcare so expensive?
People used to talk about how the military had $600 hammers and $640 toilet seats, but healthcare just says “hold my beer” to all those examples. It’s been well established that U.S. healthcare’s spending problem is not oversupply or overutilization – although there is both – but “It’s the prices, stupid.” Whether it is tests, procedures, hospital stays, prescription drugs, or anything else, in U.S. healthcare things just cost more.
Yet no one in healthcare thinks their prices are too high, and no one admits they’re making too much money. We’d hoped making patients pay more of their bills, or making prices more transparent, would make them more price conscious, but that hasn’t happened. We’ve even recently found that those big health insurers who supposedly are tough negotiators often don’t get better prices than people paying directly.
Prices are high because no one cares enough to force them to be lower. That’s silly.
How come our physicians are becoming more specialized even though we’re realizing how interdependent everything in our body is?
Primary care doctors make up at most only a third of U.S. physicians, a percentage that is both declining and well below the comparable percentage in other developed countries. Moreover, the physicians who are specialists are increasingly becoming sub-specialists. That’s great if you have only one very specific health issue, but if that issue is only one of many, or if that issue is due to or has created other health issues – as is likely – then it is not so good. It means lots of referrals, many doctors, and sometimes conflicting recommendations, Primary care doctors were supposed to coordinate everything, but, as I said, there aren’t that many of them, and they don’t have the time anyway.
If we want more holistic care, we’re training physicians wrong, we’re incenting them wrong financially, and we’re not getting anyone with the big picture of our health. That’s silly.
How come there is no one in the health care system whose job it is to keep us healthy, and who is rewarded accordingly?
Everyone in healthcare talks about wanting patients to be healthy, and many of them pay at least lip service to reminding you about doing things that might help, but let’s be clear: they get paid when you get sick (or, at least, use services). It’s not a health system in any sense; it is a health care at best, and, more accurately, a medical care system.
If you have one, a primary care doctor might claim to fill that space, but, admit it, they don’t really know what your health habits are and have little ability to influence them. Arguably, there are a great many health behaviors that are outside physicians’ training and expertise anyway. The health care system thinks about people only when they become patients, and primarily relies on reactive, medical interventions to address health issues.
Hypothetically, one can imagine a health care system in which you pay for the periods during which you are healthy, and don’t pay when you aren’t. Instead, we use a system in which the more you use it, the more you pay. That’s silly.
Since we’ve discovered that our microbiome outnumbers “us” – in terms of cells, DNA, etc. – and has direct impacts on “our” health, why does our health care still focus on “us” and not on “we”?
It was a huge step forward for medicine, and our health, when we discovered bacteria, viruses, etc., but we quickly decided they were the enemy and declared war on them. Yes, advances like penicillin have saved countless lives, but, as with many advances, we didn’t fully understand the consequences.
To the extent we think about our microbiome, it’s usually in conjunction with our gut, and mostly only in relation to our gut health, but research is showing that the gut microbiome impacts other areas of the body (such as our brain), and that our microbiome has impacts on almost all aspects of our health. Our vaunted theories of disease badly need a 21st century, microbiome-inclusive update. Like it or not, if it isn’t not healthy, we’re not healthy.
We indiscriminately kill off “good” microbes along with the “bad” ones, rather than trying to optimize the balance. That’s silly.
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Our health care system has a “The Emperor Has No Clothes” problem. Many of us realize that it is badly flawed, perhaps even irredeemable, but it is the system we have, and we figure that it would take too much to fundamentally change it. Well, that’s silly.
So I’ll keep trying to ask silly questions about healthcare and hope that others can get intimations of something totally new.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor
All eyes were on Wisconsin – not last week, but in 1847. That’s when Wisconsin newspaperman and editor of the Racine Argus, Marshall Mason Strong, let loose in a speech on the disturbing trend to allow women the right to buy and sell property. It seems the state had caught the bug from their neighbor, Michigan, which was considering loosening coverture laws.
“Coverture” is a word you may not know, but should. It was a series of laws derived from British Common Law that “held that no female person had a legal identity.” As legal historian Lawrence Friedman explained, “Essentially husband and wife were one flesh; but the man was the owner of that flesh.” From birth to death, women were held in check economically. A female child was linked by law to father’s entitlements. If she was lucky enough to be married, she lived off the legal largesse of her husband. They were one by virtue of marriage, but that one was the husband, as signified by taking his last name.
The practice derived from British law. Women were held in matrimonial bondage in England with the aid of ecclesiastical courts and the officiating presence and oversight of an Episcopalian clergyman. This meant control over getting married as well as well as the capacity to escape a marriage marred by abuse or desertion. Not that there was much call for divorce. Britain was a divorceless society. The richy rich occasionally could be freed by a special act of Parliament. But this was exceedingly rare. Between 1800 and 1836, there were less than 10 divorces granted per year in England. For the unhappy rest, it was adultery or desertion.
The divorceless society held for the first half of the 19th century in most of the states below the Mason-Dixon line, with South Carolina being the most restrictive. But every New England state had a general divorce law before 1800, as did New York, New Jersey and Tennessee. “Grounds” (which varied from state to state) were presented in an ordinary lawsuit by the innocent party.
Demand for divorce grew as America grew in the first half of the 19th century. With mobility came hardship and “odious abuse’, and increasing recognition that “a divorceless state is not necessarily a state without adultery, prostitution and fornication. It is certainly not a place where there are no drunken, abusive husbands.” And then there was the issue of property rights and its ties to economic growth in this still young nation.
America was rich in land, which rapidly translated into a fast-expanding smallholder middle-class. Relationships could shift on a dime, resulting in property disputes and threats to the legitimacy of children and one’s heirs. The numbers of land owners, fueled by westward expansion were enormous, and each had a stake in society. When push came to shove, economics won out over Puritan instincts – but not without a fight.
There were plenty of voices like Yale’s President, Timothy Dwight, who in 1816, labeled ready divorces as “stalking, barefaced pollution…one vast Brothel; one great province of the World of Perdition.” But, in a male-dominated world that featured desertion, abuse, and confusion over children’s welfare and legitimacy, rights to property, and protection from a missing husband’s debt collectors, “married women’s property acts” began to appear.
The first surprisingly was in 1839 in Mississippi, that is until you learned that the liberalization involved a married women’s rights to “own and dispose of slaves.” In 1844, Michigan weighed in narrowly by protecting a women’s inherited or earned property from her husbands post-mortem debtors.
Three years later Marshall Strong couldn’t help himself, and from his perch in Racine, Wisconsin, editorialized that the “domestic sphere” is under attack, and the consequences will be dire. “Finer sensibilities” are on the chopping block and “every trait of loveliness blotted out.” Summing up a whole family collapse – men are being “degraded, the wife unsexed, and children uncared for.” These new married women’s property laws, he writes, already have played out elsewhere. “It exists in France, and … more than one-fourth of the children annually born in Paris are illegitimate.”
And yet, three years after Strong’s lament, seventeen states, including Wisconsin, had adopted their own versions of gender equalizing property laws. Why?
According to Friedman, “The real fulcrum of change was outside the family and outside the women’s movement…The number of women with a stake in the economy had increased dramatically.”
Nor was there a big uproar in this mid-century legal turnaround. As Friedman sees it, “Little agitation preceded them; great silence followed them. It was the silence of a fait accompli.” But in history, about faces are not uncommon, and “freedom walks” can flow in both directions.
Consider the past decade in Marshall Strong’s home state. In 2010, Scott Walker, the son of a Baptist preacher, assumed the governorship of the state and quickly rose to national prominence by aggressively opposing abortion rights and torching union rights to collective bargaining in the state. In 2016 he set his sites on the Presidency, but fizzled and withdrew within two months under withering attacks from Donald Trump.
One of Walker’s last actions however, before loosing a bid for a third term as governor, was to appoint conservative lawyer, Dan Kelly, to a seat on the Wisconsin Supreme Court being vacated by retiring Justice David Prosser. Kelly’s conservative radicalism on women’s autonomy and comparing affirmative action to slavery was apparently a “bridge too far”, and he lost his seat in the 2020 reelection bid to liberal Judge Jill Karofsky. This was only the second time an incumbent judge had lost reelection in Wisconsin in the last half century.
Not to be deterred, Kelly ran again last week, and once again went down by double digits, this time to liberal circuit court judge Janet Protasiewicz. Kelly had thus single-handedly (with an assist from Scott Walker) flipped control of the Court from 5-2 conservative to 4-3 liberal.
But Kelly did not go quietly. As he stated in his concession speech, “I think this does not end well.” He plans to return to his prior passion, providing legal cover to Republicans redrawing statewide electoral maps. As for Protaciewicz, she seemed well aware that the ghost of Marshall Strong lives on in Wisconsin, saying simply, “There is still work to be done.”
Well over a third of Americans are obese — and the percentage keeps growing at a staggering rate. Over the last twenty years, obesity prevalence grew from 30% to 42% of the US population and rates of severe obesity nearly doubled. If we don’t make serious changes to our healthcare system, it’s scary to think where we’re headed in a few short years.
The fact is, obesity is far from a cosmetic condition. It can be a devastating disease and was classified as such by the American Medical Association in 2013. Obesity is the leading risk factor for deadly diseases like type 2 diabetes, heart disease, stroke, and at least 13 types of cancer.
If we don’t stop the obesity epidemic in its tracks now, we’re in for a world of hurt. People’s lives, the healthcare system, and, by extension, the US economy could be headed for collapse if we continue to ignore it. Cardiometabolic conditions like obesity, heart disease, stroke, and diabetes cost the US healthcare system upwards of $500 billion a year in healthcare costs and another $147 billion in lost workforce productivity for heart disease and stroke alone.
And yet private and government-sponsored health plans are dragging their feet to address obesity head on. They know most people jump from health plan to health plan every few years, so they’re willing to take the chance that their members with obesity won’t develop high-cost complications soon enough to justify treatment now. And yet treatment could reverse the effects of obesity and downstream chronic disease, saving lives and billions of dollars in the long run.
Forward-thinking employers and pharmacy benefit managers, on the other hand, are taking note of new obesity therapies like GLP-1s. Employers will soon start covering GLP-1s and other weight loss medications because people have longer tenure with employers than insurers and employers recognize that obesity treatment reduces healthcare costs, increases worker productivity, and has the potential to attract and retain talent.
While the cost of many weight loss drugs is steep right now, it’s inevitable that we’ll see prices come down eventually. Just like we saw insulin prices come down to $35 a month, patient advocates and lawmakers will pressure drug companies to lower the cost of weight loss drugs to more reasonable amounts. Too many people need these medications who can’t afford them at their startling price point now. And no one wants to live in a world where lifesaving drugs for the masses are only priced for celebrities to use.
As exciting as they are, however, GLP-1s aren’t going to solve obesity alone.
Healthy food should really be the premier medicine to treat obesity. The trick is how to actually integrate food into medical practice. As of now, the best way to integrate food is through Medical Nutrition Therapy prescribed by registered dietitians. Dietitians can personalize eating plans to help people with obesity make healthy food choices that will impact not just their obesity, but also co-occurring conditions like diabetes, hypertension, and cancer. Some nutritious food delivery systems and SNAP benefits show promise too.
We can’t forget that obesity is also strongly linked to depression and other mental health disorders. The mind-body connection is real with obesity sometimes causing grave changes in brain function and cognitive impairment. Conversely, depression is often thought to be an underlying cause of weight gain. Research physicians like Chris Palmer, MD, argue that “mental disorders are metabolic disorders of the brain.”
People with obesity need more mental health support in order to combat the disease and make effective behavioral changes. Studies show that treating depression and obesity together can bring greater improvements for both conditions.
Initiating and sustaining weight loss often requires a nearly herculean effort for many people. It necessitates learning new coping mechanisms and changing lifelong habits — and even still, genetics and other biological markers can work against those efforts. Nevertheless, no surgery or drug alone can fully cure someone of obesity. Experts agree that weight loss medications (GLP-1s and others) and surgery must be coupled with behavior change for sustained results.
People with obesity need the supportive care of provider teams who can prescribe Medical Nutrition Therapy, weight loss medications, and antidepressants alongside mental health coaching and cognitive behavioral therapy when necessary.
Fighting the obesity epidemic will require wholesale change. We can’t keep dismissing obesity as a personal problem of willpower. Not only is that assumption hopelessly defeating, it’s patently false. Obesity is a medical disease that’s reached epidemic proportions and our healthcare system must directly address it with evidence-based treatments like Medical Nutrition Therapy, weight loss medications, and behavioral health coaching for lasting outcomes. If we tackle obesity with our full arsenal, we have the potential to save millions of lives and billions of downstream healthcare costs.
Stephanie Tilenius is the Founder and CEO of Vida Health
Eric Topol has a piece in his excellent newsletter Ground Truth‘s today about AI in medicine. He refers to the paper he and colleagues wrote in Nature about Generalist Medical Artificial Intelligence (the medical version of GAI). It’s more on the latest in LLM (Large Language Models). They differ from previous AI which was essentially focused on one problem, and in medicine that mostly meant radiology. Now, you can feed different types of information in and get lots of different answers.
Eric & colleagues concluded their paper with this statement: “Ultimately, GMAI promises unprecedented possibilities for healthcare, supporting clinicians amid a range of essential tasks, overcoming communication barriers, making high-quality care more widely accessible, and reducing the administrative burden on clinicians to allow them to spend more time with patients.” But he does note that “there are striking liabilities and challenges that have to be dealt with. The “hallucinations” (aka fabrications or BS) are a major issue, along with bias, misinformation, lack of validation in prospective clinical trials, privacy and security and deep concerns about regulatory issues.”
What he’s saying is that there are unexplained errors in LLMs and therefore we need a human in the loop to make sure the AI isn’t getting stuff wrong. I myself had a striking example of this on a topic that was purely simple calculation about a well published set of facts. I asked ChatGPT (3 not 4) about the historical performance of the stock market. Apparently ChatGPT can pass the medical exams to become a doctor. But had it responded with the same level of accuracy about a clinical issue I would be extremely concerned!
The brief video of my use of ChatGPT for stock market “research” is below:
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