Equity Prerequisite
Demands for accessible and equitable digital respiratory health are premature and counterproductive
Late last year the European Respiratory Society (ERS) published an overview of digital respiratory health. Attracted to the first comprehensive survey of the field, and despite its annoyingly high price tag, I recently picked up a (digital) copy.
It opens with a slightly patronizing preface from Prof Peter Calverley:
“Digital medicine is moving from being a technology in search of a problem, to providing novel solutions to the challenges of expanding healthcare need.”
It’s hard to imagine technology entrepreneurs have struggled finding problems to fix. Innumerable shortcomings in the care and treatment of chronic respiratory disease mean morbidity, mortality and costs remain at near-record highs.
The dismissive start perplexed me, but how the editors’ introduction took it from there is what got me to the keyboard this weekend.
In it, they assert that digital technology, left to its own, will increase healthcare inequalities, and therefore, that its development and implementation needs to be directed to achieve a goal of “fairness.”
The editors suggest the “social challenges” of respiratory health must come first. By which they mean that healthtech companies have a duty to “optimiz[e] digital interfaces for individuals….who, for whatever reason, have limited ability to access and benefit from digital healthcare.” And that they (ie, physicians and healthcare organizations) have a responsibility to ensure “the needs of remote and/or deprived communities of demographically disadvantaged groups are addressed as a prerequisite of implementing digital healthcare.” [emphasis mine]
In the business community, technology companies are taught to solve, maybe own is a better word, the specific problems of one person. Next, ten. Then a hundred, and so on. “The perfect target market for a startup,” says Peter Thiel, “is a small group of particular people concentrated together and served by few or no competitors.” Spend a lot of time on little things. Start out in a niche and serve them well. Then expand.
Rather than build what a group of users is pulling out of the company, the “equity prerequisite” positions entrepreneurs on systemic problems. Important as those are, it’s a path to generic, standardized experiences sanctioned by consensus and guided by compliance. And no one becomes wedded to a product designed for everyone. That’s how Apple’s Asthma Health App launched in 2015 with fanfare and 50k downloads, but ended up with just 175 active users six months later.
Start too broad and you'll inevitably have to crawl back into a niche.
Early on at Propeller, we built a version of our inhaler sensor for dumb phones. It was a complicated feat of Bluetooth engineering and a naive misuse of time and resources. Health systems had objected that our technology needed to work for every patient, not just those with smartphones. Though already clear there was no trend toward fewer smartphones, we gave in to those demands. By the time it was ready two years later, no one wanted it.
The unacknowledged reality of chronic respiratory disease for health tech entrepreneurs is that the labels of asthma and COPD encompass a lot of phenotypic variation that already make them complex product challenges.
Asthma contains multitudes. As The Lancet puts it:
“The notion of asthma as one unifying disease concept is disappearing further into the realm of historical oversimplification…Asthma is at best a syndrome with different risk factors, different prognoses, and different responses to treatment.”
Different demographics, too. Asthma in kids is often not the same as it is in adults. And each of these is substantially its own experience. Even medically, the disease has no home. You may see a pediatrician, allergist, pulmonologist, or an occupational medicine physician. COPD has similar diversity.
How does one engineer and commercialize a single solution to serve all these different personas and permutations? Can you create something for a child who wheezes with viral infections that an adult with work-related asthma will also find valuable?
Add the requirements that it must also address the social challenges of healthcare—it should work well for those with poor health literacy, for example, or those who lack internet access—and the project becomes semi-quixotic.
Creative technology works by variation and selection. Each product is a conjecture about what people want. Most are refuted. So far, only a tiny fraction of people with chronic respiratory disease have had any experience with digital health.
Thankfully, we’re only beginning to imagine what’s possible now that we could not do before. One day, some ideas will gain meaningful traction among people with respiratory disease. Until then, the most productive path forward is an emergent strategy of creative (maybe opinionated) solutions focused on the specific problems of a narrow set of users. That includes interventions designed for the unique difficulties faced by disadvantaged populations.
We’re better off scaling those targeted products, successful in their limited aims and audience, than chasing mythical universal experiences that are impossibly compelling, perfectly equitable and accessible to everyone.
Early Spring Hodgepodge
Fellow anthropologist Susannah Fox has a new book out, Rebel Health, about peer-to-peer healthcare, or as the blurb tells it: “An action-oriented and radically hopeful field guide to the underground, patient-led revolution for better health and health care.” Please get yourself a copy and support her work.
If your company is working on respiratory disease, heads up that the Respiratory Innovation Summit at ATS (San Diego, May 17th) is still accepting applications. Learn more and apply here
Closed Loop Medicine, where I serve on the board, published promising results from a trial of personalized dosing of amlodipine in Journal of the American Heart Association.
This week (March 7th), I’m joining Pete Kazanjy (author of Founding Sales) in a free online session for founders put on by Kentucky’s Launch Blue accelerator. More info / register
I’ve moved my personal site to Substack, and started a “What I’m doing now” page. I’m lining up some fun stuff—eg, interviews, market overviews—for future newsletters. If you have suggestions, or feedback on the newsletter in general, please send me a note or leave a comment.
Thanks for reading!
DVS
Spot on perspective with the bruises to show for listening to the guidance to try to appease everyone. The VC community seems a bit guarded about Digital Health as a category since there have been patient compliance challenges in Remote Patient Monitoring requiring use over many days else it negates 3rd party payments, and we have seen well-funded startups crash and burn in this segment. In contrast, digital health therapy is paid per session with easily proven results for value-based-care models. However, even well-proven solutions like ours with published RCTs, FDA cleatance and $60 - $100 reimbursements face slow adoption outside of our initial target market and underscore your recommendation to focus tightly on early clients before attempting to serve the broader market.