The Algorithm Will See You Now
Artificial intelligence in medicine, still in an early phase, stands to transform how doctors and nurses spend their time.
There's a quiet revolution going on in medicine. It's driven by artificial intelligence, but paradoxically, new technology may put a more human face on healthcare.
AI's usefulness in healthcare ranges far and wide.
Artificial intelligence is software that can process massive amounts of information and learn over time, arriving at decisions with striking accuracy and efficiency. It offers greater accuracy in diagnosis, exponentially faster genome sequencing, the mining of medical literature and patient records at breathtaking speed, a dramatic reduction in administrative bureaucracy, personalized medicine, and even the democratization of healthcare.
The algorithms that bring these advantages won't replace doctors; rather, by offloading some of the most time-consuming tasks in healthcare, providers will be able to focus on personal interactions with patients—listening, empathizing, educating and generally putting the care back in healthcare. The relationship can focus on the alleviation of suffering, both the physical and emotional kind.
Challenges of Getting AI Up and Running
The AI revolution, still in its early phase in medicine, is already spurring some amazing advances, despite the fact that some experts say it has been overhyped. IBM's Watson Health program is a case in point. IBM capitalized on Watson's ability to process natural language by designing algorithms that devour data like medical articles and analyze images like MRIs and medical slides. The algorithms help diagnose diseases and recommend treatment strategies.
But Technology Review reported that a heavily hyped partnership with the MD Anderson Cancer Center in Houston fell apart in 2017 because of a lack of data in the proper format. The data existed, just not in a way that the voraciously data-hungry AI could use to train itself.
The hiccup certainly hasn't dampened the enthusiasm for medical AI among other tech giants, including Google and Apple, both of which have invested billions in their own healthcare projects. At this point, the main challenge is the need for algorithms to interpret a huge diversity of data mined from medical records. This can include everything from CT scans, MRIs, electrocardiograms, x-rays, and medical slides, to millions of pages of medical literature, physician's notes, and patient histories. It can even include data from implantables and wearables such as the Apple Watch and blood sugar monitors.
None of this information is in anything resembling a standard format across and even within hospitals, clinics, and diagnostic centers. Once the algorithms are trained, however, they can crunch massive amounts of data at blinding speed, with an accuracy that matches and sometimes even exceeds that of highly experienced doctors.
Genome sequencing, for example, took years to accomplish as recently as the early 2000s. The Human Genome Project, the first sequencing of the human genome, was an international effort that took 13 years to complete. In April of this year, Rady Children's Institute for Genomic Medicine in San Diego used an AI-powered genome sequencing algorithm to diagnose rare genetic diseases in infants in about 20 hours, according to ScienceDaily.
"Patient care will always begin and end with the doctor."
Dr. Stephen Kingsmore, the lead author of an article published in Science Translational Medicine, emphasized that even though the algorithm helped guide the treatment strategies of neonatal intensive care physicians, the doctor was still an indispensable link in the chain. "Some people call this artificial intelligence, we call it augmented intelligence," he says. "Patient care will always begin and end with the doctor."
One existing trend is helping to supply a great amount of valuable data to algorithms—the electronic health record. Initially blamed for exacerbating the already crushing workload of many physicians, the EHR is emerging as a boon for algorithms because it consolidates all of a patient's data in one record.
Examples of AI in Action Around the Globe
If you're a parent who has ever taken a child to the doctor with flulike symptoms, you know the anxiety of wondering if the symptoms signal something serious. Kang Zhang, M.D., Ph.D., the founding director of the Institute for Genomic Medicine at the University of California at San Diego, and colleagues developed an AI natural language processing model that used deep learning to analyze the EHRs of 1.3 million pediatric visits to a clinic in Guanzhou, China.
The AI identified common childhood diseases with about the same accuracy as human doctors, and it was even able to split the diagnoses into two categories—common conditions such as flu, and serious, life-threatening conditions like meningitis. Zhang has emphasized that the algorithm didn't replace the human doctor, but it did streamline the diagnostic process and could be used in a triage capacity when emergency room personnel need to prioritize the seriously ill over those suffering from common, less dangerous ailments.
AI's usefulness in healthcare ranges far and wide. In Uganda and several other African nations, AI is bringing modern diagnostics to remote villages that have no access to traditional technologies such as x-rays. The New York Times recently reported that there, doctors are using a pocket-sized, hand-held ultrasound machine that works in concert with a cell phone to image and diagnose everything from pneumonia (a common killer of children) to cancerous tumors.
The beauty of the highly portable, battery-powered device is that ultrasound images can be uploaded on computers so that physicians anywhere in the world can review them and weigh in with their advice. And the images are instantly incorporated into the patient's EHR.
Jonathan Rothberg, the founder of Butterfly Network, the Connecticut company that makes the device, told The New York Times that "Two thirds of the world's population gets no imaging at all. When you put something on a chip, the price goes down and you democratize it." The Butterfly ultrasound machine, which sells for $2,000, promises to be a game-changer in remote areas of Africa, South America, and Asia, as well as at the bedsides of patients in developed countries.
AI algorithms are rapidly emerging in healthcare across the U.S. and the world. China has become a major international player, set to surpass the U.S. this year in AI capital investment, the translation of AI research into marketable products, and even the number of often-cited research papers on AI. So far the U.S. is still the leader, but some experts describe the relationship between the U.S. and China as an AI cold war.
"The future of machine learning isn't sentient killer robots. It's longer human lives."
The U.S. Food and Drug Administration expanded its approval of medical algorithms from two in all of 2017 to about two per month throughout 2018. One of the first fields to be impacted is ophthalmology.
One algorithm, developed by the British AI company DeepMind (owned by Alphabet, the parent company of Google), instantly scans patients' retinas and is able to diagnose diabetic retinopathy without needing an ophthalmologist to interpret the scans. This means diabetics can get the test every year from their family physician without having to see a specialist. The Financial Times reported in March that the technology is now being used in clinics throughout Europe.
In Copenhagen, emergency service dispatchers are using a new voice-processing AI called Corti to analyze the conversations in emergency phone calls. The algorithm analyzes the verbal cues of callers, searches its huge database of medical information, and provides dispatchers with onscreen diagnostic information. Freddy Lippert, the CEO of EMS Copenhagen, notes that the algorithm has already saved lives by expediting accurate diagnoses in high-pressure situations where time is of the essence.
Researchers at the University of Nottingham in the UK have even developed a deep learning algorithm that predicts death more accurately than human clinicians. The algorithm incorporates data from a huge range of factors in a chronically ill population, including how many fruits and vegetables a patient eats on a daily basis. Dr. Stephen Weng, lead author of the study, published in PLOS ONE, said in a press release, "We found machine learning algorithms were significantly more accurate in predicting death than the standard prediction models developed by a human expert."
New digital technologies are allowing patients to participate in their healthcare as never before. A feature of the new Apple Watch is an app that detects cardiac arrhythmias and even produces an electrocardiogram if an abnormality is detected. The technology, approved by the FDA, is helping cardiologists monitor heart patients and design interventions for those who may be at higher risk of a cardiac event like a stroke.
If having an algorithm predict your death sends a shiver down your spine, consider that algorithms may keep you alive longer. In 2018, technology reporter Tristan Greene wrote for Medium that "…despite the unending deluge of panic-ridden articles declaring AI the path to apocalypse, we're now living in a world where algorithms save lives every day. The future of machine learning isn't sentient killer robots. It's longer human lives."
The Risks of AI Compiling Your Data
To be sure, the advent of AI-infused medical technology is not without its risks. One risk is that the use of AI wearables constantly monitoring our vital signs could turn us into a nation of hypochondriacs, racing to our doctors every time there's a blip in some vital sign. Such a development could stress an already overburdened system that suffers from, among other things, a shortage of doctors and nurses. Another risk has to do with the privacy protections on the massive repository of intimately personal information that AI will have on us.
In an article recently published in the Journal of the American Medical Association, Australian researcher Kit Huckvale and colleagues examined the handling of data by 36 smartphone apps that assisted people with either depression or smoking cessation, two areas that could lend themselves to stigmatization if they fell into the wrong hands.
Out of the 36 apps, 33 shared their data with third parties, despite the fact that just 25 of those apps had a privacy policy at all and out of those, only 23 stated that data would be shared with third parties. The recipients of all that data? It went almost exclusively to Facebook and Google, to be used for advertising and marketing purposes. But there's nothing to stop it from ending up in the hands of insurers, background databases, or any other entity.
Even when data isn't voluntarily shared, any digital information can be hacked. EHRs and even wearable devices share the same vulnerability as any other digital record or device. Still, the promise of AI to radically improve efficiency and accuracy in healthcare is hard to ignore.
AI Can Help Restore Humanity to Medicine
Eric Topol, director of the Scripps Research Translational Institute and author of the new book Deep Medicine, says that AI gives doctors and nurses the most precious gift of all: time.
Topol welcomes his patients' use of the Apple Watch cardiac feature and is optimistic about the ways that AI is revolutionizing medicine. He says that the watch helps doctors monitor how well medications are working and has already helped to prevent strokes. But in addition to that, AI will help bring the humanity back to a profession that has become as cold and hard as a stainless steel dissection table.
"When I graduated from medical school in the 1970s," he says, "you had a really intimate relationship with your doctor." Over the decades, he has seen that relationship steadily erode as medical organizations demanded that doctors see more and more patients within ever-shrinking time windows.
"Doctors have no time to think, to communicate. We need to restore the mission in medicine."
In addition to that, EHRs have meant that doctors and nurses are getting buried in paperwork and administrative tasks. This is no doubt one reason why a recent study by the World Health Organization showed that worldwide, about 50 percent of doctors suffer from burnout. People who are utterly exhausted make more mistakes, and medical clinicians are no different from the rest of us. Only medical mistakes have unacceptably high stakes. According to its website, Johns Hopkins University recently announced that in the U.S. alone, 250,000 people die from medical mistakes each year.
"Doctors have no time to think, to communicate," says Topol. "We need to restore the mission in medicine." AI is giving doctors more time to devote to the thing that attracted them to medicine in the first place—connecting deeply with patients.
There is a real danger at this juncture, though, that administrators aware of the time-saving aspects of AI will simply push doctors to see more patients, read more tests, and embrace an even more crushing workload.
"We can't leave it to the administrators to just make things worse," says Topol. "Now is the time for doctors to advocate for a restoration of the human touch. We need to stand up for patients and for the patient-doctor relationship."
AI could indeed be a game changer, he says, but rather than squander the huge benefits of more time, "We need a new equation going forward."
Is Carbon Dioxide the New Black? Yes, If These Fabric-Designing Scientists Have Their Way
The entrepreneurs Tawfiq Nasr Allah (left, standing) and Benoit Illy (right, sitting down) at Fairbrics' lab in Clichy, France.
Each year the world releases around 33 billion tons of carbon dioxide into the atmosphere. What if we could use this waste carbon dioxide to make shirts, dresses and hats? It sounds unbelievable. But two innovators are trying to tackle climate change in this truly unique way.
Chemist Tawfiq Nasr Allah set up Fairbrics with material scientist Benoît Illy in 2019. They're using waste carbon dioxide from industrial fumes as a raw material to create polyester, identical to the everyday polyester we use now. They want to take a new and very different approach to make the fashion industry more sustainable.
The Dark Side of Fast Fashion
The fashion industry is responsible for around 4% of global emissions. In a 2015 report, the MIT Materials Systems Laboratory predicted that the global impact of polyester fabric will grow from around 880 billion kg of CO2 in 2015 to 1.5 trillion kg of CO2 by 2030.
Professor Greg Peters, an expert in environmental science and sustainability, highlights the wide-ranging difficulties caused by the production of polyester. "Because it is made from petrochemical crude oil there is no real limit on how much polyester can be produced...You have to consider the ecological damage (oil spills, fracking etc.) caused by the oil and gas industry."
Many big-name brands have pledged to become carbon neutral by 2050. But nothing has really changed in the way polyester is produced.
Some companies are recycling plastic bottles into polyester. The plastic is melted into ultra-fine strands and then spun to create polyester. However, only a limited number of bottles are available. New materials must be added because of the amount of plastic degradation that takes place. Ultimately, recycling accounts for only a small percentage of the total amount of polyester produced.
Nasr Allah and Illy hope they can offer the solution the fashion industry is looking for. They are not just reducing the carbon emissions that are conventionally produced by making polyester. Their process actually goes much further. It's carbon negative and works by using up emissions from other industries.
"In a sense we imitate what nature does so well: plants capture CO2 and turn it into natural fibers using sunlight, we capture CO2 and turn it into synthetic fibers using electricity."
Experts in the field see a lot of promise. Dr Phil de Luna is an expert in carbon valorization -- the process of converting carbon dioxide into high-value chemicals. He leads a $57-million research program developing the technology to decarbonize Canada.
"I think the approach is great," he says. "Being able to take CO2 and then convert it into polymers or polyester is an excellent way to think about utilizing waste emissions and replacing fossil fuel-based materials. That is overall a net negative as compared to making polyester from fossil fuels."
From Harmful Waste to Useful Raw Material
It all started with Nasr Allah's academic research, primarily at the French Alternative Energies and Atomic Energy Commission (CEA). He spent almost 5 years investigating CO2 valorization. In essence, this involves breaking the bonds between the carbon and oxygen atoms in CO2 to create bonds with other elements.
Recycling carbon dioxide in this way requires extremely high temperatures and pressures. Catalysts are needed to break the strong bonds between the atoms. However, these are toxic, volatile and quickly lose their effectiveness over time. So, directly converting carbon dioxide into the raw material for making polyester fibers is very difficult.
Nasr Allah developed a process involving multiple simpler stages. His innovative approach involves converting carbon dioxide to intermediate chemicals. These chemicals can then be transformed into the raw material which is used in the production of polyester. After many experiments, Nasr Allah developed new processes and new catalysts that worked more effectively.
"We use a catalyst to transform CO2 into the chemicals that are used for polyester manufacturing," Illy says. "In a sense we imitate what nature does so well: plants capture CO2 and turn it into natural fibers using sunlight, we capture CO2 and turn it into synthetic fibers using electricity."
The Challenges Ahead
Nasr Allah met material scientist Illy through Entrepreneur First, a programme which pairs individuals looking to form technical start-ups. Together they set up Fairbrics and worked on converting Nasr Allah's lab findings into commercial applications and industrial success.
"The main challenge we faced was to scale up the process," Illy reveals. "[It had to be] consistent and safe to be carried out by a trained technician, not a specialist PhD as was the case in the beginning."
They recruited a team of scientists to help them develop a more effective and robust manufacturing process. Together, the team gained a more detailed theoretical understanding about what was happening at each stage of the chemical reactions. Eventually, they were able to fine tune the process and produce consistent batches of polyester.
They're making significant progress. They've produced their first samples and signed their first commercial contract to make polyester, which will then be both fabricated into clothes and sold by partner companies.
Currently, one of the largest challenges is financial. "We need to raise a fair amount to buy the equipment we need to produce at a large scale," Illy explains.
How to Power the Process?
At the moment, their main scientific focus is getting the process working reliably so they can begin commercialization. In order to remain sustainable and economically viable once they start producing polyester on a large scale, they need to consider the amount of energy they use for carbon valorization and the emissions they produce.
The more they optimize the way their catalyst works, the easier it will be to transform the CO2. The whole process can then become more cost effective and energy efficient.
De Luna explains: "My concern is...whether their process will be economical at scale. The problem is the energy cost to take carbon dioxide and transform it into these other products and that's where the science and innovation has to happen. [Whether they can scale up economically] depends on the performance of their catalyst."
They don't just need to think about the amount of energy they use to produce polyester; they also have to consider where this energy comes from.
"They need access to cheap renewable energy," De Luna says, "...so they're not using or emitting CO2 to do the conversion." If the energy they use to transform CO2 into polyester actually ends up producing more CO2, this will end up cancelling out their positive environmental impact.
Based in France, they're well located to address this issue. France has a clean electricity system, with only about 10% of their electric power coming from fossil fuels due to their reliance on nuclear energy and renewables.
Where Do They Get the Carbon Dioxide?
As they scale up, they also need to be able to access a source of CO2. They intend to obtain this from the steel industry, the cement industry, and hydrogen production.
The technology to purify and capture waste carbon dioxide from these industries is available on a large scale. However, there are only around 20 commercial operations in the world. The high cost of carbon capture means that development continues to be slow. There are a growing number of startups capturing carbon dioxide straight from the air, but this is even more costly.
One major problem is that storing captured carbon dioxide is expensive. "There are somewhat limited options for permanently storing captured CO2, so innovations like this are important,'' says T. Reed Miller, a researcher at the Yale University Center for Industrial Ecology.
Illy says: "The challenge is now to decrease the cost [of carbon capture]. By using CO2 as a raw material, we can try to increase the number of industries that capture CO2. Our goal is to turn CO2 from a waste into a valuable product."
Beyond Fashion
For Nasr Allah and Illy, fashion is just the beginning. There are many markets they can potentially break into. Next, they hope to use the polyester they've created in the packaging industry. Today, a lot of polyester is consumed to make bottles and jars. Illy believes that eventually they can produce many different chemicals from CO2. These chemicals could then be used to make paints, adhesives, and even plastics.
The Fairbrics scientists are providing a vital alternative to fossil fuels and showcasing the real potential of carbon dioxide to become a worthy resource instead of a harmful polluter.
Illy believes they can make a real difference through innovation: "We can have a significant impact in reducing climate change."
Vaccine passports, if required by businesses and universities, may give people a false sense of security, one expert cautions.
Vaccines are one of the greatest public health accomplishments of all time. For centuries, public health has relied on vaccinations to prevent and control disease outbreaks for a plethora of infectious scourges, with our crowning achievement being the successful eradication of smallpox.
The purpose of vaccine documentation is to provide proof of an individual's protection from either becoming infected or transmitting a vaccine-preventable disease. Vouching for these protections requires a firm knowledge about the epidemiology of the disease, as well as scientific knowledge concerning the efficacy of the vaccine. The vaccines we currently require be documented have met these tests; the vaccine for COVID-19 has not yet been proven to do so.
Let's acknowledge that the term "vaccine passport" is a poor choice of words. Passports are a legal travel document created by nations and governed by law for identification of the bearer to control entry and exit from nation states. They often serve as legal forms of identification and as a record of international travel. They are generally very sophisticated documents that have been created in a secure manner and may include a range of electronic and, in some cases, biometric measures such as fingerprints to ensure the holder is indeed who they say they are. Vaccine passports are medical documents used to document the vaccination status of an individual. They do not undergo the same level of administrative scrutiny and cannot be used to verify that the presenter is indeed the vaccinated individual. Some companies do have electronic methods to address concerns about verification; however, most people currently have paper records that can be easily falsified.
"Vaccine passports" as currently proposed risk giving people a false sense of security.
Successful disease control from vaccination programs relies on the ability to vaccinate at a level that prevents large-scale disease spread and the ability to rapidly identify the presence of disease outbreaks. It requires reliable, safe, and effective vaccines that are easily delivered in clinical and nonclinical settings. Keeping vaccination information as a part of the medical record, and even having a separate specialized vaccine record for personal use, is a time-honored tradition.
Keeping a vaccination record provides a method to keep track of the many shots one receives and serves as a visual reminder to help ensure the appropriate vaccine shot schedule is maintained for vaccines requiring multiple doses. The vaccine record, when combined with vaccine safety monitoring systems, serves as a mechanism to track adverse events to monitor and ensure the safety of vaccines as a consumer product. The record also serves as the official record of vaccination when required for administrative or legally prescribed purposes.
"Vaccine passports" as currently proposed risk giving people a false sense of security. In the case of the COVID-19 vaccines currently approved for use, many of the essential questions remain unanswered. While we do know the current three vaccines are highly protective against severe disease and death, and there is some evidence that these vaccinations do reduce infections and virus transmission of SARS-CoV-2, we do not yet know the full degree to which this occurs.
For example, we know there have been some cases of people that have been infected in close proximity to getting their full vaccination and rare cases of breakthrough reinfections. A breakthrough infection in a restaurant is a challenge for contact tracing, but an outbreak from a movie theater exposure or a baseball game could spark a major outbreak at our current level of vaccination. Current CDC guidance recommends continued mask wearing in order to address these concerns.
We also do not yet know how long the protections will last and if or when a booster or revaccination is required. In effect, it is too soon to know. Should an annual booster shot be required, then a vaccine passport would require annual updating, a process more frequent than renewal of a driver's license.
We also know that the current SARS-CoV-2 virus is mutating briskly. While the current approved vaccines have remained effective overall, there is evidence of some degree of degradation in vaccine effectiveness against some of the circulating strains. We also have sparse data on many of the other emerging strains of concern because we have not had the surveillance capacity in the U.S. to gain an adequate sense of how the virus is changing to fully align vaccine effectiveness with viral capabilities.
The risk of people misusing these "passports" is troubling. The potential for using these documents for hiring, firing or job limitation is a serious concern. Unvaccinated workers are at risk of this form of discrimination even from well-meaning employers or supervisors. Health insurers are prohibited by the Affordable Care Act from discriminating based on preexisting conditions, but they could probably charge a higher premium for unvaccinated individuals. There also is a risk of stigmatizing individuals who are not vaccinated or have left their vaccine documentation at home. Another concern: the opportunity to discriminate based on race, gender, sexual orientation, or religion, using one's vaccination status as an excuse.
These "passports" are being discussed as a "ticket verification" for entry to many activities, including dining at restaurants, flying domestically and/or internationally, going to movie theaters and sporting events, etc. These are all activities we already are doing at reduced levels and for which wearing a mask, hand hygiene and physical distancing are effective disease control practices. COVID-19 vaccines are indeed the measure that will make the ability to totally reopen our society complete, but we are not there yet. Documentation of one's COVID-19 vaccine status may be useful in selected situations in the future. That remains to be seen.
Finally, inadequate vaccine supply and disparities in vaccine delivery have created enormous challenges in providing equal access to vaccination. Also, the amount of misinformation, disinformation, and lingering vaccine hesitancy continue to limit the speed at which we will reach the level of vaccination of the population that would make this documentation meaningful. The requirement for "vaccine passports" is already alienating people who are opposed to vaccinations for a variety of reasons, paradoxically risking reduced vaccine uptake. This politicization of the vaccination effort is of concern. There are indeed people who, due to medical contraindications or legal exemptions, will not be vaccinated, and we do not yet have a national framework on how to address this.
Vaccine passports are not the solution for reopening our society — a robust vaccination program is. The requirement to document one's vaccination status for COVID-19 may one day have its place. For now, it is an idea whose time has not yet come.
Editor's Note: This op/ed is part of a "Big Question" series on the ethics of vaccine passports. Read the flip side argument here.