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  • Katalin Karikó and Drew Weissman were awarded the 2023 Nobel Prize for Physiology or Medicine for pioneering the use of messenger RNA (mRNA) as a therapeutic tool for vaccines
  • mRNA translates genetic instructions from DNA to cellular machinery, driving essential protein synthesis in cell biology
  • Karikó and Weissman’s innovations led to the development of the first mRNA vaccine to combat the Covid-19 virus
  • Katalin Karikó overcame significant professional and personal setbacks before becoming a world-renowned scientist
  • Her life changed after a chance meeting with Weissman, which resulted in their ground-breaking contribution to biomedical science and the Nobel Prize
 
A Nobel Journey: Triumph over Adversity, Serendipity, BioNTech’s Rise, and mRNA Marvels
 
On Monday 2nd October 2023, Katalin Karikó and Drew Weissman were awarded the Nobel Prize in Physiology or Medicine for their contributions to messenger RNA (mRNA) biology that led to the unprecedented rate of vaccine development during the Covid-19 pandemic.
 
In this Commentary

This Commentary has four sections. In Part 1, Triumph over adversity, we highlight the journey of Katalin Karikó, which is a testament to her indomitable spirit. Despite facing entrenched prejudices and significant setbacks, Karikó's brilliance eventually triumphed, earning her the respect she deserved. As her work gained prominence, she emerged as a passionate advocate for women in science. Part 2, Serendipity, briefly describes a chance encounter between Karikó and Drew Weissman, which triggered a collaboration that defied the odds, and resulted in a major contribution to biomedical science that safeguarded the health and wellbeing of billions throughout the world and gained them the Nobel Prize. Part 3, “BioNTech doesn’t even have a website”, outlines the role played by a German start-up founded in 2008 by a husband-and-wife team, which leveraged Karikó's expertise and developed the first mRNA vaccine for the Covid-19 virus - a significant feat with global ramifications. The concluding Part 4, mRNA marvels, explains the science and describes the early contribution of Roger Kornberg, which enhanced our understanding of the molecular machinery that underpins mRNA’s functions. Also, we focus on how Karikó and Weissman championed the practical implications of mRNA for its use as a therapeutic. The combined endeavours advanced the field of molecular biology and opened unprecedented frontiers in both basic research and transformative therapeutic innovations. Takeaways follow.
 
Part 1

Triumph over adversity

Born in 1955 in a small town in central Hungary, Katalin Karikó grew up in a household devoid of running water, a refrigerator, or a television. From a young age she became fascinated with science, which led to her developing a passion for biology.
 
In 1982, she obtained a PhD from the University of Szeged, Hungary. Her research explored how mRNA could be used to target viruses: an innovative endeavour as gene therapy was in its infancy. Recognizing the therapeutic potential of mRNA, Karikó secured a postdoctoral position at the Biological Research Centre (BRC) of the Hungarian Academy of Sciences, where she embarked on a journey to advance her research.
 
At this time, Hungary was under Communist rule as part of the Eastern Bloc. The prevailing socio-political environment presented challenges for Karikó, which included glass ceilings that were obstacles for her scientific ambitions. After two years of research, her funding abruptly ceased: an illustration of the volatile and uncertain conditions she faced during those early years.
 
Buoyed by a boom in mRNA research taking place in the US, Karikó turned her gaze towards America and landed a research position at Temple University in Philadelphia. She sold her car, converted the proceeds into 900 British pounds on the Black Market, and sewed the currency into her two-year-old daughter's teddy bear to facilitate taking them out of Hungary. In the US in the late 1980s, she entered a male-dominated scientific community and encountered the prevalent gender biases and stereotypes: unequal opportunities, limited representation in leadership roles, and both subtle and overt discrimination.
 
In 1988, Karikó accepted a position at Johns Hopkins University in Baltimore without notifying Temple University. This prompted her sponsor to report her to the US immigration authorities, accusing her of being "illegally" in the country. After successfully challenging the resulting extradition order, Karikó faced another setback as Johns Hopkins withdrew her job offer. However, she secured a research position at the Uniformed Services University of the Health Services in Bethesda, Maryland.
 
A year later, in 1989, the University of Pennsylvania recognized her talent and hired her. Karikó dedicated her research to exploring the therapeutic potential of mRNA, envisioning its use to stimulate protein production within the human body. Her research faced scepticism during a time when synthetic mRNA applications for therapeutics were met with doubt. During clinical studies, the injection of mRNA-based therapies into animals triggered a severe inflammatory response, resulting in the death of the subjects, thereby eliminating any possibility of human trials.
 
Consequently, the excitement around mRNA as a therapy faded, and securing funding for such research became impossible. Karikó received multiple rejections from funding agencies. Her inability to raise research monies led the university in 1995 to suggest that she was "not of faculty quality" and presented her with an ultimatum: "leave or be demoted". This was a devastating and demeaning blow for Karikó who was on a tenured career path to become a full professor. She decided to accept an untenured position with a reduced salary and persevered in her research.

Even in the face of demotion and funding rejections, Karikó showed resilience. Overcoming doubts and questions from the scientific community is no small feat. It demands an unusual form of persistence and a deep belief in the value of one's research. She had to reconcile staying true to her visionary ideas and adapting to the feedback around her. What makes Karikó’s story even more remarkable is the personal adversity she faced. Amidst her professional challenges, her husband encountered visa problems, which obliged him to return to Hungary for six months. During this period, she was diagnosed with cancer, underwent two operations while simultaneously caring for her daughter and maintaining her research.

 
Part 2

Serendipity

Serendipity played a significant role in Karikó's scientific journey, as her fascination with mRNA had to endure a time when its potential was largely doubted by the scientific community. A critical turning point for her was a chance encounter with Drew Weissman, a senior professor of immunology at the University of Pennsylvania, who was well-endowed with research funds.
 
In the late 1990s, Karikó and Weissman bumped into each other at a photocopier. At that time, scientists copied the latest research from journals. Their meeting led to a recognition of a shared vision and complementary skills, and together, they pushed the boundaries of what was deemed possible. Their collaboration addressed challenges associated with using synthetic mRNA as a therapeutic tool. Weissman's expertise in immunology, combined with Karikó's focus on mRNA and protein synthesis, led to breakthroughs in modifying mRNA to reduce its inflammatory response and increase its stability.
 
In retrospect, Karikó's journey, coupled with her collaboration with Weissman, not only showcased scientific acumen but also emphasised the transformative potential of collaborative efforts in advancing the boundaries of knowledge. Their partnership became a catalyst for ground-breaking discoveries, particularly in the development of modified mRNA.

 
Part 3

“BioNTech doesn’t even have a website”

BioNTech, a German start-up founded in 2008 by a dynamic husband-and-wife team, Uğur Şahin and Özlem Türeci, was launched without a website but had a mission to disrupt healthcare. In 2013, Karikó accepted an invitation to join the company as a senior vice-president. When she told her University colleagues they are reported to have laughed at her saying that the company does not even have a website. Later Karikó and Weissman licenced the mRNA technology they developed to BioNTech, which later partnered with Moderna and Pfizer. BioNTech’s partnership with Pfizer, a giant pharmaceutical company experienced in vaccine development and distribution, led to a global clinical trial of Karikó and Weissman’s mRNA tool as a therapy, which involved >43,000 individuals across six countries. The joint venture became a linchpin in the fight against the Covid-19 virus. Today, BioNTech is a Nasdaq traded company with a market cap of ~US$23bn, annual revenues of >US$18bn, >4,500 employees and research centres in San Diego and Cambridge, Massachusetts.
  
Unknown to Karikó and Weissman, in 2005, Derrick Rossi, while a postdoctoral researcher in molecular biology at Stanford University in California was impressed with a paper they published describing a modified form of mRNA that did not induce an immune response. In 2010, Rossi, together with colleagues from Harvard and MIT, founded Moderna, which, between 2011 and 2017, raised US$2bn in venture capital funding and later formed its partnership with BioNTech. In the throes of the global Covid-19 pandemic, BioNTech emerged as a pioneer, developing the first authorized mRNA vaccine by leveraging Karikó and Weissman's mRNA technology. This breakthrough had a competitive edge over traditional vaccines because it offered a faster and more efficacious solution. In April 2020, as the world clamoured for a solution to the Covid-19 virus, Moderna secured a significant boost, receiving US$483m from the US Biomedical Advanced Research and Development Authority to fast-track its Covid-19 programme. Today, Moderna, based in Cambridge, Massachusetts, is a Nasdaq traded company with a market cap >US$30bn, annual revenues of ~US$20bn, and a workforce of ~4,000.
 
From a humble start without a website to shaping the future of medicine, the stories of BioNTech and Moderna exemplify the transformative power of scientific innovation and unwavering determination.

 
Part 4

mRNA marvels
 
The molecular messenger: mRNA
mRNA functions act like a postal service of the genetic world, which takes instructions from the DNA in the cell’s nucleus and delivers them to the protein-producing machinery called ribosomes in the cell’s cytoplasm [a jelly-like substance that fills the cells and surrounds the nucleus]. Think of it as a template that guides the creation of proteins in a process known as translation. So, mRNA is the messenger that ensures the right genetic instructions reach the protein-making machinery, which helps cells produce specific proteins needed for different tasks.
 

Importance of mRNA in protein synthesis
mRNA plays a crucial role in protein synthesis, serving as the intermediary that carries genetic instructions from DNA to the ribosomes. This process is significant for several reasons: mRNA transfers the genetic code from DNA to the ribosomes in the cytoplasm, ensuring the accurate transmission of instructions for protein synthesis. Each mRNA molecule corresponds to a specific protein, providing the specificity needed for the synthesis of diverse proteins with distinct functions. The regulation of mRNA production allows cells to control when and how much of a particular protein is synthesized, contributing to the adaptation of cellular processes. Proteins are essential for the structure, function, and regulation of cells. The diversity and specificity of proteins determine the many functions that cells can perform. Thus, mRNA acts as a messenger, translating the genetic information stored in DNA into functional proteins, thereby influencing all cellular activities and maintaining the integrity and functionality of living organisms.
 

The transcription process and the role of RNA polymerase II
Transcription is the first step in the flow of genetic information, where a segment of DNA is used as a template to synthesize a complementary RNA molecule. RNA polymerase II plays an important role in this process, particularly in the transcription of protein-coding genes. Let us give a brief overview. Transcription begins with the binding of RNA polymerase II to a specific region of DNA called the promoter. This signals the start of the gene to be transcribed. Once bound to the promoter, RNA polymerase II unwinds the DNA double helix and starts synthesizing an RNA molecule complementary to one of the DNA strands. As it progresses along the DNA, RNA polymerase II adds nucleotides to the emerging RNA chain, always extending it in the 5’ to 3’ direction. Transcription continues until the RNA polymerase II encounters a termination signal in the DNA. This signals the end of transcription, and the RNA polymerase II detaches from the DNA template. The newly synthesized RNA molecule, called pre-mRNA, undergoes processing steps like capping, splicing, and polyadenylation to form mature mRNA. These modifications enhance stability, functionality, and transport of the mRNA. RNA polymerase II is responsible for transcribing protein-coding genes (mRNA). It recognizes the promoter sequences of these genes and catalyses the synthesis of the complementary mRNA strand. The precision and regulation of this process are vital for ensuring accurate gene expression and the production of functional proteins in cells.
Science made easy

Importance of mRNA in protein synthesis
Think of mRNA as a messenger in the protein-making factory of your cells. It is like the delivery person that carries important instructions from the cell's recipe book (DNA) to the protein-making machines (ribosomes). Here is why this messenger - mRNA - is important: (i) Accurate Delivery: mRNA ensures that the instructions from the recipe book (DNA) are accurately delivered to the protein-making machines (ribosomes) in the cell's kitchen (cytoplasm). (ii) Specific Recipes: Each mRNA molecule has a specific recipe for a particular protein. This specificity is important because it helps in making different proteins with different jobs in the cell. (iii) Controlled Production: Cells can control when and how much of a protein is made by managing the production of mRNA. It is like having control over how often and how many times a specific recipe is used in the kitchen. And (iv) Cellular Teamwork: Proteins are like the workers in the cell - they build structures, carry out functions, and regulate processes. mRNA, by delivering the right protein recipes, ensures that the cell's team is diverse and has the skills needed for various tasks. So, mRNA is the messenger that translates the genetic information stored in DNA into practical instructions for making proteins. This process is like the secret sauce that keeps the cell running smoothly and maintains the overall health and function of living organisms.

The transcription process and the role of RNA polymerase II
Imagine your DNA is like a cookbook, and you want to make a specific recipe from it. Transcription is the first step in this cooking process. RNA polymerase II is like the chef who reads the recipe and makes a copy of it.  The chef (RNA polymerase II) starts by finding the beginning of the recipe, which is called the promoter. Then, s/he reads the instructions in the recipe (DNA) and creates a matching copy in the form of RNA. This copy, known as pre-mRNA, undergoes some additional steps to become the final recipe (mature mRNA). The chef follows the recipe precisely from start to finish, and when s/he reaches the end of the instructions or sees a "stop" sign (termination signal), s/he finishes the job. The final recipe (mature mRNA) is then ready to be used in the kitchen (cell) to make a delicious dish (functional protein). This whole process is crucial to ensure that the right recipes are selected and copied accurately, leading to the creation of the correct proteins needed for the cell's functions.
Synthetic mRNA
Beyond its natural role, synthetic mRNA acts as a vaccine, directing cells to produce specific viral proteins, prompting an immune response without inducing illness. Initially, challenges arose with unwanted inflammation caused by early versions of these genetic instructions. Katalin Karikó and Drew Weissman addressed this issue by making adjustments, preventing inflammation, and enhancing target protein production. This breakthrough laid the groundwork for vaccine development.
 

mRNA, Roger Kornberg, Katalin Karikó and Drew Weissman
We have described how mRNA serves as a critical messenger, shuttling genetic instructions from the cell's nucleus to the protein-building ribosomes. Now, let us briefly describe the contribution to the field of Roger Kornberg, an American biochemist who, in 2006, was awarded the Nobel Prize in Chemistry for his research on RNA polymerase II, the enzyme central to transcribing DNA into mRNA. In the video below Kornberg explains his research interest in how biological information, encoded in the human genome, is accessed to inform all human activity.
 

Kornberg's research went beyond simply decoding genetic information; he illuminated the intricacies of transcription - the process translating DNA into RNA. Specifically, his work dissected the structure of RNA polymerase II uncovering the nuances of how RNA polymerase II interacts with DNA during transcription. This detailed molecular blueprint is central to understand how genetic instructions in DNA are accurately transcribed into mRNA, which, as we described above, is a crucial step in the cellular flow of genetic information.
 
Katalin Karikó and Drew Weissman built upon Kornberg’s insights and spearheaded the application of mRNA for therapeutic purposes. While they championed the practical implications of mRNA, Kornberg’s contributions enhanced our understanding of the molecular machinery that underpins mRNA’s functions. Their combined endeavours advanced the field of molecular biology and opened unprecedented frontiers in both basic research and transformative therapeutic innovations.
 
Takeaways
 
This Commentary tells a story of science, resilience, serendipity, and a ground-breaking achievement. We described the scientific intricacies of mRNA, flagging Roger Kornberg's pioneering contributions. A testament to the triumph of the human spirit, portrayed Katalin Karikó's journey: her brilliance, overcoming prejudice and blossoming into advocacy for women in science. The unexpected collaboration between Karikó and Weissman, which led to a biomedical breakthrough that transcended expectations, ultimately garnering the Nobel Prize. We introduced BioNTech, where a husband-and-wife team harnessed Karikó and Weissman’s innovative research to pioneer the development of the world's first mRNA vaccine to combat the Covid-19 virus. This not only marked a historic moment in biomedical science but also exemplified the power of collaboration, determination, and visionary leadership. As we reflect on this journey - from the molecular intricacies of mRNA to the global impact of a life-saving vaccine - it becomes clear that the convergence of scientific curiosity, individual tenacity, and collaboration can be a catalyst for transformative change. The 2023 Nobel Prize for Physiology or Medicine awarded to Katalin Karikó and Drew Weissman stands as recognition of their central role in reshaping the landscape of biomedical science and, more importantly, in safeguarding the health and wellbeing of billions throughout the world. In scientific discovery, their story serves as an inspiring chapter, encouraging us to embrace the boundless possibilities that arise when science and humanity join forces in the pursuit of a healthier, more resilient future.
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Because of recent concerns raised by the UK’s Health Security Agency (UKHSA),colleagues suggested that we republish a Commentary entitled, “Slowing the steep rise in antimicrobial resistance”, which features Nobel Laureate Roger Kornberg. Since it was first published it has received >15,000 openings. UKHSA warned of a “hidden pandemic” this winter because last year, in the UK, 1 in 5 infections were resistant to antibiotic. The organization feared that as COVID-19 restrictions are lifted social mixing is likely to spread infections some of which will be resistant to antibiotics.
 
  • Currently 700,000 people die each year from Antimicrobial Resistance (AMR) and this could rise to 10 milion by 2050
  • AMR could make routine surgeries and childbirth as dangerous and lethal as in the pre-antibiotic era killing millions and costing trillions worldwide
  • Doctors inappropriately prescribing antibiotics for minor aliments shorten the useful life of antibiotics threatening modern medicine as there is an antibiotic pipeline deficiency
  • 90% of GPs feel pressured by patients to prescribe antibiotics
  • 70% of GPs are unsure whether sore throat and respiratory infections are viral or bacterial resulting in 50% of sore throats receiving antibiotics
  • Clinical diagnosis leads to 50% of patients with a sore throat being prescribed antibiotics without having Group A Streptococcal infection
  • 30% of patients with pharyngitis will not be treated but will be infected with Group A Streptococci
  • 24% of doctors say they lack easy-to-use diagnostic tools
  • 10m prescriptions for antibiotics are handed out in England each year to patients who do not need them
  • A Nobel Laureate has developed a new technology to provide rapid, accurate, cost-effective diagnosis of bacterial sore throat resulting in informed prescribing and reducing unnecessary antibiotic usage
 
Slowing the steep rise of antimicrobial resistance
 
Should we listen when a professor of medicine and a Nobel Laureate says that the technology already exists to develop a cheap hand held device, which can rapidly and accurately diagnose a bacterial sore throat?  
 
Without such a device to determine whether minor ailments require antibiotics, doctors will continue to prescribe them, and thereby contribute to the steep rise in Antimicrobial Resistance (AMR). In 2016 the National Institute for Health and Care Excellence (NICE), the UK government's NHS watchdog, reported that as many as 10m prescriptions for antibiotics are handed out in England every year to patients who do not need them. According to a 2016 report on AMR, by 2050 a staggering, “10m people will die from AMR each year . . . . The world needs rapid diagnostics to improve our use of antibiotics,” says the report.
 

Sore throat
 
Acute throat infections are among the most common infectious diseases presented to primary healthcare and A&E departments and are frequently misdiagnosed. They are responsible for 2 to 4% of all primary care visits. Viruses cause 85% to 95% of throat infections in adults and children younger than 5. For those aged 5 to 15, viruses cause about 70% of throat infections, with the other 30% due to bacterial infections, mostly group A β-hemolytic streptococcus (GAS), which can cause 0.5m deaths a year. There are challenges in diagnosing GAS because its signs and symptoms are often indistinguishable from viral and other causes of sore throat.
 
If a doctor intends to treat suspected GAS pharyngitis, it is generally recommended that laboratory confirmation of the presence of GAS be sought to limit unnecessary antibiotic prescription. The gold standard laboratory investigation is of a bacterial culture of a throat swab. However, this is expensive, and there is a relatively long lag time between the collection of the specimen and final microbiological diagnosis: so doctors tend not to it. 
 
Rapid antigen diagnostic tests (RADTs) are an alternative to the gold standard laboratory test for GAS. However, widespread use of RADTs has been hindered by low sensitivity for most commonly used RADTs (immunoassays). Reviews of RADTs performance have identified significant variability in the diagnostic accuracy, especially sensitivity, between different test methodologies.

 
Urgent need for rapid and accurate diagnostic test
 
A principal recommendation of a 2016 report on AMR is to ban doctors from prescribing antibiotics until they have carried out rapid tests to prove the infection is bacterial. The report also stresses that doctors need urgent help to temporise their use of antibiotics if AMR is to be reduced.

Notwithstanding, the AMR challenge is bigger than doctors overprescribing antibiotics. Farmers feed antibiotics to livestock and poultry, and spray them on crops to make our food supply ‘safer’. We dump antibiotics in rivers, and even paint them on the hulls of boats to prevent the build up of barnacles. However, it seems reasonable to suggest that successfully reducing doctors’ over prescribing antibiotics would represent a significant contribution to denting the burden of AMR. To do this, “We need a step change in the technology available . . . Governments of the richest countries should mandate now that, by 2020, all antibiotic prescriptions will need to be informed by up to date surveillance and a rapid diagnostic test,” urges the AMR report.
 
The technological ‘step change’, which the report says is essential, has already been achieved, says Roger Kornberg, Professor of Medicine at Stanford University and Nobel Laureate for Chemistry.Advanced biosensor technology enables virtually instantaneous, extraordinarily sensitive, electronic detection of almost any biomarker (protein, nucleic acid, small molecule, etc.). With relatively modest resources it would only be a matter of months to develop a simple, affordable handheld device, which not only would tell you immediately and accurately whether a sore throat requires antibiotics or not, but would also tell you which antibiotics you require, and for how long you should take them,” says Kornberg. See videos below in which Kornberg describes how tried and tested biosensor technology could facilitate rapid and accurate diagnosis of a sore throat.


Click to watch a cluster of videos by Professor Kornberg on Antimicrobial resistance and biosensor technology
Serious and growing threat
 
Each year, millions of people throughout the developed world present themselves to their doctors with minor ailments, such as a sore throat. 97% of these patients demand antibiotics although 90% of their ailments are viral and therefore do not require antibiotics. 90% of doctors, who do not have the means to rapidly and accurately determine whether a minor ailment requires antibiotics, feel pressured by patients to prescribe them.
 
A 2014 study of four million NHS patients from 537 GP practices in England found that more than 50% of those presenting with a minor ailment were prescribed antibiotics, despite warnings that the medication will not help, but increases their risk of developing resistance. The study, by scientists at Public Health England and University College London, published in the Journal of Antimicrobial Chemotherapy, found that antibiotic prescriptions for minor ailments increased by some 40% between 1999 and 2011. 70% of GPs surveyed said they prescribed antibiotics because they were unsure whether patients had viral or bacterial infections, and 24% of GPs said it was because of a lack of an easy-to-use, rapid and accurate diagnostic device.
 
Superbugs will kill millions and cost trillions
 
Concerned about the rising levels of drug resistance whereby microbes evolve to become immune to known drugs, in 2014 the UK Government, in collaboration with the Wellcome Trust, commissioned a review of the large and growing global burden of AMR. Jim O’Neill, a former Goldman Sachs chief economist who coined the phrase “BRICS”, was appointed to lead the endeavour and propose actions to tackle AMR. In 2015 O’Neill was elevated to the House of Lords, and appointed Secretary to the UK government’s Treasury.

During the 18 months it took O’Neill to complete his final report, one million people worldwide died from AMR. At least 25,000 people die each year in Europe from AMR. According to the Centers for Disease Control and Prevention (CDC), more than 2m people in the US become infected with resistant bacteria every year, and at least 23,000 of them die. According to O’Neill, “If we don't do something about antibiotic resistance, we will be heading towards a world with no-antibiotic treatments for those who need them.”
 
A threat to modern medicine
 
O’Neill’s findings are congruent with warnings from the World Health Organization (WHO), which suggests AMR is a crisis worse than the Aids epidemic – which has caused some 25m deaths worldwide – and threatens to turn the clock back on modern medicine. The misuse of antibiotics has created, “A problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” says a 2014 WHO report. “Superbugs risk making routine surgery potentially lethal, killing millions and costing the world economy US$100 trillion a year by the middle of the century,” says O’Neill.
 
These dire warnings are supported by a case study of AMR published in Antimicrobial Agents and Chemotherapy in 2016, which suggests that we might be closer to a "post-antibiotic era" than we think. A particular group of bacteria (Gram-negative) have become increasingly resistant to currently available antimicrobial drugs. Colistin is one of the only antibiotics that still show some effectiveness against such infections, but the study suggests that even Colistin may no longer be effective.
 
Takeaways
 
AMR is widely recognized as a serious and growing worldwide threat to human health. New forms of AMR continue to arise and spread, leaving doctors with few weapons to bring potentially life-threatening infections under control. The injudicious use of antimicrobials, and the proliferation of AMR pathogens are compounded by the inability to rapidly and accurately diagnose minor ailments such as sore throats. Professor Kornberg has an answer.
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  • The CoVID-19 pandemic has been controlled by government policies that restrict individual behaviour 
  • Even if the accelerated vaccine development goes to plan and is successful, government restrictions will be necessary for some time yet 
  • Recent research suggests that, at the height of the CoVID-19 pandemic, people with narcissistic and other “dark” personality traits flouted public health restrictions  
  • Research has also shown that the coronavirus can be spread by a relatively small group of individuals who break public health protocols 
  • Could a small group of asymptomatically infected individuals with narcissistic traits trigger a renewed and significantly more devastating outbreak of CoVID-19?
  
Narcissism and a second more devastating wave of CoVID-19
 
 
Research suggests that in early 2020, at the height of the CoVID-19 pandemic, people with narcissistic and other “dark” personality traits, (Machiavellianism and psychopathy) flouted public health restrictions, such as social distancing, stay-at-home measures, mask-wearing and hand washing, introduced to prevent the spread of the coronavirus.
 
The fastest and deepest global economic shock in history

The outbreak of CoVID-19 in December 2019 started an epidemic of acute respiratory syndrome in humans in Wuhan, China, which quickly became a pandemic responsible for the fastest and deepest global economic shock in history. In a matter of weeks, stock markets collapsed, credit markets froze, huge bankruptcies occurred, unemployment rose above 10% and annual GDP rates contracted by 8% or more. In the absence of either a vaccine or a therapy, the social and behavioural sciences were used by governments to help align human behaviour with the recommendations of epidemiologists and public health experts to reduce the impact of the coronavirus outbreak. 
 
Measures were successful and as nations regained control of the virus’s transmission and reduced the burden on their healthcare systems, restrictions were relaxed or removed to re-energise damaged economies and encourage more viable lifestyles with the virus still in circulation. In many countries, this increased the incidence levels of CoVID-19, hospitalisations and deaths; and governments had no alternative but to re-instate selected restrictions on people’s behaviours.
 
Now, some ten months after the initial outbreak, governments throughout the world are bracing themselves in the knowledge that a relatively small group of people who flout restrictions could cause the coronavirus to return, which some analysts suggest could be more devastating than the impact of its initial outbreak. This is because healthcare systems have been significantly weakened and are struggling to cope with huge backlogs of patients whose treatments have been delayed because of the coronavirus, economies have been damaged, and the annual winter flu epidemic is expected in most Western developed nations.
 
In this Commentary

This Commentary describes the findings of three recent studies, which examine the relationships between the Dark Triad traits (i.e., narcissism, Machiavellianism and psychopathy) and behaviours related to the COVID-19 pandemic. Findings suggest that, at the height of the pandemic in March and April 2020, people with narcissistic and psychopathic personality traits were more likely to ignore rules, such as hand washing, social distancing, staying-at-home and mask-wearing and therefore could have become super spreaders of the disease. The Commentary focusses on narcissistic traits. We begin by underlining some of the challenges of developing and manufacturing a CoVID-19 vaccine at scale, which is safe and effective. We then describe Narcissistic Personality Disorder (NPD) and the R number, which governments have used to explain how well the virus is being controlled. We also describe the lesser known K metric, which is critical to epidemiologists’ attempts at understanding how CoVID-19 is actually transmitted. We then briefly describe the concepts of super spreaders and super-spreading events, which help to explain how a relatively small group of people can have a significant impact on the transmission of the coronavirus. Brief descriptions of the findings of three recent research studies follow. These suggest that people with narcissistic and other “dark” personality traits, break public health restrictions. Finally, we draw attention to the limitations of the studies and provide some “takeaways”.
 
Developing and scaling vaccines is challenging

Although scientists look likely to produce a CoVID-19 vaccine much faster than anyone could have predicted, and governments have pre-purchased about 4bn doses of these for delivery at the end of 2020, developing a safe and effective vaccine at scale is challenging. The failure rate of vaccines that reach advanced clinical trials is as high as 80%. Some CoVID-19 vaccines in production that receive regulatory approval might only provide partial or temporary protection, others might require more than one dose to be effective. So, even if the accelerated vaccine development goes to plan and is successful, it is not altogether clear whether this would secure protection for enough people throughout the world to halt the spread of the virus in the medium term. Thus, it seems reasonable to assume that, behavioural techniques to slow or stop the spread of the coronavirus will be needed for some time yet, and people with narcissistic personality traits could reduce the effectiveness of these endeavours.
 

Narcissistic Personality Disorder

Narcissism is a pattern of grandiosity, a need for admiration and a lack of empathy. The condition has its genesis  in Greek mythology, and a beautiful and proud young man called Narcissus, the son of the river god Cephissus and the nymph Liriope. Many fell in love with Narcissus, but he only showed them disdain and contempt. When Nemesis, the goddess of retribution and revenge, learned of this she decided to punish Narcissus for his behaviour and led him to a pool where he saw his reflection in the water and fell in love with it. Narcissistic personality disorder (NPD) is rare. Although the term NPD has been used since 1968, only in 1980 was it officially recognized in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, which is a taxonomic and diagnostic manual published by the American Psychiatric Association. Notwithstanding, in all probability we all know someone with narcissistic tendencies, which we often dismiss as just a “big ego” problem. And, if we are honest, at some point in our lives, we have demonstrated some narcissistic traits. The signs and symptoms of NPD include: (i) having an exaggerated sense of self-importance and a sense of entitlement, (ii) wanting constant, excessive admiration, (iii) expecting to be recognized as superior even without achievements that warrant it, (iv) exaggerating achievements and talents, (v) believing that you are superior and desiring to associate with equally ‘special’ people, (vi) having an inability or unwillingness to  recognize the needs and feelings of others, (vii) expecting special favours and unquestioning compliance, and (viii) taking advantage of others to get what you want. Although research in social and personality psychology has added significantly to our general understanding of narcissism, it has been one of the least studied personality disorders, mainly because of its low societal urgency and health costs. The causes of NPD are unknown, and the condition remains a controversial diagnosis. Some researchers think that overprotective or neglectful parenting styles may have an impact. Genetics and neurobiology also may play a role in the development of NPD. Given the challenges of diagnosing the condition, prevalence rates vary significantly. For instance, in the US, reported prevalence in the general population varies from 0.5% to 5%. NPD is less frequently identified in psychiatric settings, but more often seen in private clinical settings and applied to higher-functioning patients.
 
R number

In early 2020, during the height of the coronavirus crisis, politicians throughout the world and public health officials constantly referred to the R or R0 number to indicate the spread of the virus. As a consequence, most people now know that R refers to the average number of people one person with coronavirus is likely to infect. R is calculated through a combination of data and modelling, which includes hospital and intensive care admissions, people testing positive, deaths and surveys of people’s contacts. R indicates whether the number of infected people is increasing or decreasing. When R is above 1, the virus will grow exponentially in a population with no immunity. At 1, the disease remains steady. Below 1, the virus will gradually infect fewer people, until the epidemic dries up. However, in real life, some people with the disease infect many others, while others with the coronavirus do not spread the disease at all. This means that the R number hides significant differences between individuals and their impact on virus transmission.
K number

To compensate for this, epidemiologists use an additional metric referred to as K, which describes the pattern of CoVID-19 transmission. K is the statistical value, which indicates  the variability in the number of new coronavirus cases that each person has infected. A high K value (>5), tells us that most people are generating similar numbers of secondary cases. A low value for K (>1)  tells us that a small number of infected people can trigger significant numbers of new cases relatively quickly.
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Key to controlling CoVID-19

Epidemiologists believe the K number, or the role played by variable transmission of the coronavirus, is critical to controlling its spread. Notwithstanding, what makes controlling the transmission of the coronavirus more challenging is the fact that many highly infectious people are asymptomatic. According to research findings of a paper published in the June 2020 edition of The Annals of Internal Medicine, 40% to 45% of those infected by CoVID-19 display no signs or symptoms of the disease at all, which suggests that, “the virus might have a greater potential than previously estimated to spread silently and deeply through human populations”. Thus, understanding why and how the virus is transmitted is key to gaining control of the CoVID-19 pandemic and stopping a second wave of cases.
 
Super-spreaders

As we have suggested, there is wide variability in the behaviours of infected individuals and their subsequent roles in spreading the coronavirus. A paper published in the June 2020 edition of Wellcome Open Research analysed the spread of CoVID-19 from China and estimated the K value to be as low as 0.1.  This suggested that 80% of new coronavirus cases were caused by only about 10% of infected individuals. An infected individual who breaks the rules is likely to generate significantly more secondary cases that an infected person who does not broach public health protocols. The Wellcome paper demonstrates how a relatively small number of infected people who flout government guidelines could become ‘super-spreaders’ and cause CoVID-19 to quickly rebound, even if locally eradicated. Thus, identifying and tracking super-spreaders, is fundamental to preventing future outbreaks.
 
Super spreading events

Super spreaders are responsible for super spreading events, which are not well understood and are challenging to study. Although there is no universally agreed definition of a super spreading event, it is generally assumed to be an incident in which someone passes on the virus to six or more people. Examples of super-spreading events of CoVID-19 include outbreaks in Seoul nightclubs in South Koreameat packing plants in the US and overcrowded clothes factories in the UK.
 
Three studies

We now turn to the findings of three recent research studies, which suggest that some super-spreaders of CoVID-19 might be people with specific personality traits. The first study we describe is entitled, “Adaptive and Dark Personality Traits in the Covid-19 Pandemic”. It is published in the June 2020 edition of the Journal of Social Psychological and Personality Science and was carried out by Pavel Blagov, who is the director of the Personality Laboratory at Whitman College, USA. The second and third studies are Polish and both published in the July 2020 edition of  Journal of the International Society for the Study of Individual Differences. One is entitled “Adaptive and maladaptive behavior during the COVID-19 pandemic”, and was conducted by researchers from SWPS University of Social Sciences and Humanities, Poland. The third study is entitled, “Who complies with the restrictions to reduce the spread of COVID-19?”, which was carried out by researchers from the University of Warsaw.
 
The Whitman College Study

In late March 2020, Blagov surveyed 502 American adults, to assess their personalities and gauge how compliant they were with public health protocols for reducing the impact of CoVID-19 such as; social distancing, wearing protective gear or following basic hygiene rules. While the majority of participants reported adherence to public health restrictions, some did not. The  study found that individuals with the so-called "Dark Triad" personality traits (narcissism, Machiavellianism and psychopathy) were more likely to purposely disregard protocols intended to reduce the spread of the coronavirus. The respondents who showed disinterest in the recommended health procedures scored higher on sub-traits of meanness and disinhibition. According to Blagov, it is possible that rule breakers become super-spreaders of CoVID-19 and “have a disproportionate impact on the pandemic by failing to protect themselves and others”.  

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At the height of the pandemic, narcissists and others with dark personality traits tended to act contrary to public health recommendations. They showed less inhibition to risk and disregarded other people's safety; manifestations of which included, not covering themselves when sneezing or coughing in public, touching communal facilities, not staying at home, not keeping their distance from others and not washing their hands frequently. The  study concludes that, “there may be a minority of people with particular personality styles (on the narcissism and psychopathy spectrum) that have a disproportionate impact on the pandemic by failing to protect themselves and others.”
The  SWPS Study

These findings are supported by the  SWPS study, which is based on an online survey of 755 people (332 male and 423 female) between 15th and 29th March 2020, which was during the first month of the national CoVID-19 lockdown in Poland. The cohort was middle class with ages ranging from 18 to 78, (M = 45.83, SD = 14.98). Over 40% of the participants had either a high school or a university education.  Findings suggest that people with narcissistic or psychopathic tendencies were more likely to hoard essentials during lockdown mainly because they had a heightened sense of entitlement, which manifested itself in being greedier and more competitive.

Also, researchers suggest that participants with narcissistic personalities tend to be self-centred and lack empathy, and therefore more likely to exploit other people. People with psychopathic tendencies may be more cruel, deceitful and manipulative while coming across superficially charming.  According to Bartłomiej Nowak, the lead author of the study, narcissists are: (i) more impulsive, (ii) focused on self-interest, (iii) tend toward risk-taking and (iv) less likely to comply with measures to reduce the spread of the coronavirus.

 
The Warsaw Study

The Warsaw study set out to use the CoVID-19 pandemic to understand who complies with public health restrictions  to reduce the spread of the coronavirus. Researchers hypothesised that narcissistic and psychopathic personality traits of rivalry and lack of empathy may be associated with less compliance towards government imposed coronavirus restrictions. The study was based on an online survey carried out between 14th and 30th April 2020, which was at the height of the coronavirus crisis in Europe. There were 263 participants (27.8% male, 71.5% female, 0.8% “other”) aged between 18 and 80  (M = 28.96, SD = 10.64) and about half (49%) had a university education. 
 
The study’s findings support those of the previous two studies described above. Researchers found that compliance with public health guidelines to control CoVID-19 was low among participants who had narcissistic tendencies. Participants scoring low on agreeableness and high on aspects of narcissism and psychopathy were less likely to comply with public health restrictions. People with narcissistic traits had a sense of entitlement and perceived the restrictions as the Government forcing its will upon them.
 
Limitations of the studies

All three studies have limitations, which include being based upon relatively small samples. Data are cross sectional rather than time series and collected at the beginning of public health restrictions when it seems reasonable to assume that “people may be more likely to engage in prevention and adhere to restrictions”. The US and Poland are both developed economies with different cultures that might not be relevant for other regions of the world and, in the case of the two Polish studies, participants were drawn from a relatively homogeneous group.
 
Takeaways

Findings of the three studies described in this Commentary are not sufficiently robust to definitively say that people with narcissistic traits are super-spreaders of CoVID-19. Not everyone who defies coronavirus restrictions does so because of dark personality characteristics. Indeed, there are many factors at play in understanding behaviours during the coronavirus pandemic. Notwithstanding, from the evidence presented in the three papers, it seems reasonable to suggest that people with narcissistic tendencies, and who are asymptomatically infected with the coronavirus, could become super-spreaders and have a disproportionate impact on the transmission of CoVID-19.
 
#coronavirus #pandemic #coVID-19 #narcissism
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Since we first published this Commentary just over a year ago it’s received over 10,000 views. We’re republishing it  as colleagues have suggested that the digitization of MedTech is more relevant today because of the impact CoVID-19 has had on the industry.
  • Two Boston Consulting Group studies say MedTech innovation productivity is in decline
  • A history of strong growth and healthy margins render MedTechs slow to change their outdated business model
  • The MedTech sector is rapidly shifting from production to solutions
  • The dynamics of MedTechs' customer supply chain is changing significantly and MedTech manufacturers are no longer in control
  • Consolidation among buyers - hospitals and group purchasing organisations (GPO) - adds downward pressure on prices
  • Independent distributors have assumed marketing, customer support and education roles
  • GPO’s have raised their fees and are struggling to change their model based on aggregate volume
  • Digitally savvy new entrants are reinventing how healthcare providers and suppliers work together
  • Amazon’s B2B Health Services is positioned to disrupt MedTechs, GPOs and distributors 
  • MedTech manufacturers need to enhance their digitization strategies to remain relevant
 
MedTech must digitize to remain relevant
 
MedTech companies need to accelerate their digital strategies and integrate digital solutions into their principal business plans if they are to maintain and enhance their position in an increasingly solution orientated healthcare ecosystem. With growing focus on healthcare value and outcomes and continued cost pressures, MedTechs need to get the most from their current portfolios to drive profitability. An area where significant improvements might be made in the short term is in MedTechs' customer facing supply chains. To achieve this, manufacturing companies need to make digitization and advanced analytics a central plank of their strategies.
 
In this Commentary
 
This Commentary describes the necessity for MedTechs to enhance their digitization strategies, which are increasingly relevant, as MedTech companies shift from production to solution orientated entities. In a previous Commentary we argued that MedTechs history of strong growth and healthy margins make them slow to change and implement digital strategies. Here we suggest that the business model, which served to accelerate MedTechs' financial success over the past decade is becoming less effective and device manufacturers need not only to generate value from the sale of their product offerings, but also from data their devices produce so they can create high quality affordable healthcare solutions. This we argue will require MedTechs developing  innovative strategies associated with significantly increasing their use of digital technology to enhance go-to-market activities, strengthen value propositions of products and services and streamline internal processes.
 
MedTechs operate with an outdated commercial model
 
Our discussion of digitization draws on two international benchmarking studies undertaken by the Boston Consulting Group (BCG). The first,  published in July 2013 and entitled, “Fixing the MedTech Commercial  Model: Still Deploying ‘Milkmen’ in a Megastore World” suggests that the high gross margins that MedTech companies enjoy, particularly in the US, hide unsustainable high costs and underdeveloped commercial skills. According to BCG the average MedTech company’s selling, general and administrative (SG&A) expenses - measured as a percentage of the cost of goods sold -  is 3.5 times higher than the average comparable technology company. The study concludes that MedTechs' outdated business model, dubbed the “milkman”, will have to change for companies to survive. 
 
BCG’s follow-up 2017 study
 
In 2017 BCG published a follow-up study entitled, “Moving Beyond the ‘Milkman’ Model in MedTech”, which surveyed some 6,000 employees and benchmarked financial and organizational data from 100 MedTech companies worldwide, including nine of the 10 largest companies in the sector. The study suggested that although there continued to be downward pressure on device prices, changes in buying processes and shrinking gross margins, few MedTech companies “have taken the bold moves required to create a leaner commercial model”.
 
According to the BCG’s 2017 study, “Overall, innovation productivity [in the MedTech sector] is in decline. In some product categories, low-cost competitors - including those from emerging markets - have grown rapidly and taken market share from established competitors. At the same time, purchasers are becoming more insistent on real-world evidence that premium medical devices create value by improving patient outcomes and reducing the total costs of care”. The growth and spread of value-based healthcare has shifted the basis of competition beyond products, “toward more comprehensive value propositions and solutions that address the entire patient pathway”. In this environment, MedTechs have no choice but to use data to deliver improved outcomes and a better customer experience for patients, healthcare providers and payers.
 
MedTech distributors increasing their market power and influence
 
Although supply chain costs tend to be MedTechs' second-highest expense after labour, companies  have been reluctant to employ digital strategies to reduce expenses and increase efficiencies. As a consequence, their customer supply chains tend to be labour intensive relationship driven with little effective sharing of data between different territories and sales teams. Customer relations are disaggregated with only modest attention paid to patients and payors and insufficient emphasis on systematically collecting, storing and analysing  data to support value outcomes.  
As MedTech manufacturers have been slow to develop strong and effective data strategies, so MedTech distributors have increased their bargaining power through M&As and internationalisation. Some distributors have even assumed marketing, customer support and education roles, while others have launched their own brands. MedTechs' response to these changes has been to increase their direct sales representatives. However, consolidation among buyers - hospitals and GPO’s -  and the extra downward pressure this puts on prices, is likely to make it increasingly costly for MedTechs to sustain large permanent sales forces. 

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Advantages of distributors but no way to accurately measure sales performance

Notwithstanding, the distributor model is still common with MedTechs and has been successful in many markets for a long time. Independent distributors are often used when producers have small product portfolios. In smaller markets, distributors are employed primarily to gain economies of scale as they can combine portfolios of multiple companies to create a critical mass opportunity and  obtain better and faster access to markets.
 
MedTechs have a history of investing in sales force effectiveness (SFE) typically to increase the productivity of sales representatives. Sales leaders have some indication that this pays-off through incremental revenue growth and profits, but they struggle to assess the true performance of such investments not least because SFE includes a broad range of activities and also it is almost impossible to obtain comparative competitor data.
 
Changing nature of GPOs
 
GPO’s also have changed. Originally, they were designed in the early 20th century to bring value to hospitals and healthcare systems by aggregating demand and negotiating lower prices among suppliers. Recently however they have raised their fees, invested in data repositories and analytics and have been driving their models and market position beyond contracting to more holistic management of the supply chain dynamics. Notwithstanding, many GPO’s are struggling to change their model based on aggregate volume and are losing purchasing volume amid increasing competition and shifting preferences.
 
New entrants
The changing nature of MedTechs' customer supply chain and purchasers increasingly becoming concerned about inflated GPO prices have provided an opportunity for data savvy new entrants such as OpenMarketsThe companyprovides healthcare supply chain software that stabilizes the equipment valuation and cost reduction and aims to reinvent how healthcare providers and suppliers work together to improve the way healthcare equipment is bought and sold. OpenMarkets’ enhanced data management systems allow providers to better understand what they need to buy and when. The company represents over 4,000 healthcare facilities and more that 125 equipment suppliers; and provides a platform for over 32,000 products, which on average sell for about 12% less than comparable offerings. In addition, OpenMarkets promotes cost efficiency and price transparency as well as stronger collaboration between providers and suppliers.
 
Amazon’s B2B Health Services
 
But potentially the biggest threat to MedTech manufacturers, GPOs and distributors  is Amazon’s B2B Health Services, which is putting even more pressure on MedTechs to rethink their traditional business models and to work differently with healthcare providers and consumers. With a supply chain in place, a history of disrupting established sectors from publishing to food and a US$966bn market cap, Amazon is well positioned to disrupt healthcare supply chain practices, including contracting. In its first year Amazon’s B2B purchasing venture generated more than US$1bn and introduced three business verticals: healthcare, education and government. Already, hundreds of thousands of medical products are available on Amazon Business, from hand sanitizers to biopsy forceps. According to Chris Holt, Amazon’s B2B Health Services program leader, “there is a needed shift from an old, inefficient supply chain model that runs on physical contracts with distributors and manufacturers to Amazon's marketplace model”.

If you look at the way a hospital system or a medical device company cuts purchase orders, identifies suppliers, shops for products, or negotiates terms and conditions, much of that has been constrained by what their information systems can do. I think that has really boxed in the way that companies’ function. Modern business and the millennials coming into the workplace, can’t operate in the old way,” says Holt.

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Millennials are used to going to Amazon and quickly finding anything they need; even the most obscure items. According to Holt, “A real example is somebody who wants to find peanut butter that is gluten-free, non-GMO, organic, crunchy and in a certain size. And they want to find it in three to five clicks. That’s the mentality of millennial buyers at home, and they want to be able to do the same things at work. . . . The shift from offline traditional methods to online purchasing is very significant. It is our belief that the online channel is going to be the primary marketplace for even the most premium of medical devices in the future. That trend is already proven by data. So, we’ve created a dedicated team within Amazon Business to enable medical product suppliers to be visible and participate in that channel.
MedTechs fight back
 
According to the two BCG reports, MedTech companies can fight back by using digital technologies to strengthen and improve their go-to-market activities. This, according to BCG, would enhance MedTechs' connectivity with their customers and help them to learn more about their needs. Indeed, employing digitization to improve customer-facing activities could help standardise order, payment and after-sales service behaviour by defining and standardizing terms and conditions. This could provide the basis to help MedTechs increase their access to a range of customers - clinicians, institutions, insurers and patients - and assist them to tailor their engagements to the personal preferences of providers and purchasers. This could provide customers with access to product and service information at anytime, anywhere and could form the basis to implement broader digitalized distribution management improvements, which focus on value-based affordable healthcare in the face of escalating healthcare costs and variable patient outcomes.
 
Predictive models
 
Many companies use predictive-modelling tools to forecast demand and geo-analytics to speed delivery and reduce inventories. Online platforms provide customers with an easy way to order products and services, transparently follow their shipping status and return products when necessary. Barcodes and radio-frequency identification (RFID) chips, which use electromagnetic fields to automatically identify and track tags that contain electronically stored information attached to products, help customers track orders, request replenishments and manage consignment stock.
 
Back-office improvements
 
Further, the 2017 BCG study suggests that MedTechs only have made limited progress in improving their back-office operations. Many manufacturers  have more employees in their back offices than they do in their customer-facing functions and fail to leverage economies of scale. There is a significant opportunity for MedTechs to employ digital strategies to enhance the management of their back-office functions, including centralizing certain activities that are currently conducted in multiple individual countries.
 
Takeaway
 
For the past decade MedTech manufactures have been slow to transform their strategies and business models and still have been commercially successful. Some MedTech companies are incorporating digital capabilities into their products by connecting them to the Internet of Things (IoT), which potentially facilitate continuous disease monitoring and management. Notwithstanding, such efforts tend to be isolated endeavours - “one-offs” - and are not fully integrated into companies’ main strategies. This could run the risk of MedTech executives kidding themselves that they are embracing digitization while underinvesting in digital technologies. The two BCG studies represent a significant warning since digitization is positioned to bring a step-change to the MedTech sector, which potentially could wound successful manufacturers if they do not change.
 
Post scriptum
 
CoVID-19 has forced MedTechs to temporarily digitize their sales and marketing strategies as doctors and hospitals have restricted physical access, but still many MedTech companies look forward to returning to their single rep-based go-to market strategy when the coronavirus crisis is over. The question MedTechs need to ask themselves is, “Do our customers think that digital means of receiving sales and marketing information are significantly more effective and therefore should become permanent?”.
 


#COVID19 #pandemic #coronavirus #MedTech #internetofthings #IoT
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  • The CoVID-19 pandemic created an unprecedented global shock and killed hundreds of thousands
  • Nations responded by closing their borders, implementing stringent lockdowns and saying the  world is at war with a common invisible adversary
  • Responses to the outbreak diverged in the different regions of the world
  • Asian countries responded rapidly and effectively
  • The US and UK responded slowly and ineffectively
  • Observers suggested that the divergent responses to CoVID-19 signal a shift in power and influence from West to East
  • National responses alone are insufficient to effectively deal with the coronavirus
  • Only by embracing effective international cooperation will governments protect their citizens and safely exit the CoVID-19 crisis
 
National leaders have described the coronavirus CoVID-19 pandemic as “the enemy”. In attempts to protect their citizens, nations turned inwards and closed their borders, implemented stringent lockdown restrictions and suggested that the world is at war with a common adversary it cannot see. The speed and effectiveness of national responses to the new coronavirus crisis differed, but not even the wealthiest, most advanced nations were able to protect their citizens. The global coronavirus crisis made millions seriously ill, killed hundreds of thousands, destroyed industries, bankrupted thousands of companies, caused economies to nose-dive and threw societies into turmoil. Only by avoiding nationalist policies and embracing effective international cooperation will governments protect their citizens and safely exit the CoVID-19 crisis.
 
Viruses are notoriously difficult to treat and cure

CoVID-19 has rapidly spread throughout the world with a scale and a severity not witnessed since the devastating Spanish Flu in 1918. So-called because Spain was neutral during WW1 and was one of the few countries where journalists were free to report on the outbreak. In an era before antibiotics and vaccines, the Spanish Flu claimed the lives of nearly 0.68m Americans, 0.25m Britons and between 50 to 100m people worldwide. Adjusting for population growth, that is equivalent to between 200 and 425m today.
 
At the time of writing - June 2020 - neither an adequate therapy nor a vaccine has been developed and CoVID-19 remains prevalent in populations throughout the world. Even with today’s scientific advances, infectious diseases are notoriously challenging to either treat or cure: an Ebola vaccine was more than two decades in the making; despite the first cases of the human immunodeficiency virus (HIV) presenting in 1983, we still do not have a therapeutic preventative vaccine for the disease; nor do we have a vaccine for severe acute respiratory syndrome (SARS), a killer coronavirus, which also originated in China and was unknown before its outbreak in 2002.
 
Recovery will neither be straightforward nor quick

Notwithstanding, governments have lifted lockdown restrictions in order to get their economies working again. V, U, W and L are letters of the alphabet used to describe the shape of a recovery following the economic crisis caused by CoVID-19. Stringent lockdowns forced economies into unprecedented cold storage, and no one knows what shape a recovery will take since professional forecasters have never encountered anything like the sheer magnitude of the current economic crisis.
 
The Bank of England’s Monetary Policy Report published in May 2020, warned that the coronavirus has caused the worst economic crisis in 300 years. So, emerging from this is unlikely to be either straightforward or quick. National responses to the coronavirus outbreak were mixed. Although it is too soon to know the longer-term effects of the virus, China, Singapore and South Korea are among the countries that responded early and effectively, while the US and UK, together with other Western European countries, responded late and less effectively. As of June 1, China, with a population of 1.4bn, had 83,017 confirmed cases and 4,634 deaths; South Korea with a population of 52m, had 11,537 cases and 270 deaths,  and Singapore with a population of 5.7m, had 34,884 confirmed cases and 23 deaths.
 
In this Commentary

This Commentary describes the divergent national responses to the CoVID-19 pandemic; in particular that of China, Singapore, South Korea, the US and UK. China’s more effective response might have been because Beijing benefitted from the lessons it learned after the SARS epidemic in 2002. Governments also differed in their approaches to lifting restrictions. China’s approach was slower than that of the US and more determined to make some of the unexpected benefits thrown up by the crisis permanent. Some observers perceive such variances as a difference between liberal and illiberal nations. Others view the divergences as a shift in power and influence from West to East. We suggest that the divergent responses and outcomes are a product of the capacity and legal authority of different states and reveal different mindsets and competing views about solutions. We also contend that the devastation created by the pandemic will only be resolved with effective international cooperation. However, it is difficult to see this happening in the near term as the pandemic has become a theatre for a wider political disagreement between the US and China, in which other nation states are being forced to take sides.
 
Asian nations won the battle against CoVID-19

China, Singapore and South Korea leveraged the collectivists mindset of their citizens, their centralised authority and digital infrastructures to quickly implement the gold standard “test-trace-and-isolate” strategy to reduce and control the virus. The reason for such prompt actions and the subsequent relatively low number of cases and deaths in these Asian countries is described by  Byung-Chul Han, a South Korean-born German Professor of Philosophy at the Universität der Künste in Berlin. In an article published on May 22, in the Spanish newspaper El Pais, Han suggests that Asian nations won the battle against the CoVID-19 outbreak because their citizens, “have a collectivists mindset, which comes from their cultural tradition of Confucianism. Asians are less rebellious and more obedient than people in the West. They trust the state more. Daily life is much more organised, and Asians are strongly committed to digital surveillance. The epidemics in Asia are fought not only by virologists and epidemiologists but also by computer scientists and big data specialists”.
 
Confucian mindset rather than authoritarianism

Given Iran’s response to CoVID-19 has been less effective, it seems reasonable to suggest that the Confucian mindset, rather than authoritarianism, appears to provide at least a short-term advantage. In early March, at the Shia Muslim Masumeh shrine in the holy city of Qom, pilgrims licked and kissed its gates. Qom experienced Iran’s first outbreak of the coronavirus and became the country's worst-hit city. Shortly afterwards the government closed all major Shia shrines across the Islamic republic and reopened them again in late May. As of June 1, Iran with a population of 81m, had confirmed 154,000 cases of CoVID-19 and 7,878 deaths.  

 

Smaller democracies appear to cope well

Small democracies such as New Zealand and Greece seem to raise some doubt about Han’s thesis because they too have effectively responded to the outbreak. As of June 1, New Zealand, with a population of 5m, had confirmed 1,154 cases and 22 deaths and Greece, with a population of 11m, had a total of 2,917 cases and 175 deaths.
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Notwithstanding, New Zealand’s lockdown only occurred after significant pressure was applied by civil society that suggested the government needed to change track. Both New Zealand and Greece have concentrations of political power, access for vested interest, a lack of public participation in politics and weak media. Further, Greece had no choice but to act swiftly and robustly to the coronavirus outbreak because the country has been in an almost constant state of austerity management since 2008, which has significantly reduced its resources to tackle an outbreak of this magnitude. In both countries the effect of stringent nation-wide lockdowns could further weaken already fragile civil societies, media and parliamentary systems by concentrating power in political leaders, curtailing civil liberties, adjourning parliaments and restricting the normal operations of the media.
 
The Swedish exception

By contrast to all other developed countries, Sweden exercised a radical laissez faire no-lockdown approach to the CoVID-19 outbreak. The architect of this was the Swedish State Epidemiologist Anders Tegnell, who argued that, “nothing [to do with lockdowns] has any scientific basis”, particularly decisions to close schools because there is no evidence that children are a major cause of coronavirus transmission. In Sweden, primary and secondary schools, day care centres, restaurants, bars, cafés, cinemas, theatres, shops and places of work all remained open as normal, with Swedish health authorities relying on voluntary social distancing and people choosing to work from home. Schools for over-16s and universities were closed, and gatherings of more than 50 people were banned. As of June 1, as the death toll has fallen substantially in other European countries, 4,403 people had died from CoVID-19 in Sweden, a country with a population of 10m. Its neighbours, Denmark, Finland and Norway - each with populations of about 5m - have recorded death tolls of 574, 320 and 236, respectively.
 
Not only does Sweden’s no-lockdown approach enjoy significant support among its citizens, it also has the backing of Jonathan Sumption, an historian and a former Justice of the Supreme Court of the UK. Writing in The Times of London Sumption suggests that, “The lesson of CoVID-19 is brutally simply. . . . . . Free people make mistakes and willingly take risks. If we hold politicians responsible for everything that goes wrong, they will take away our liberty so that nothing can go wrong. They will do this not for our protection against risk, but for their own protection against criticism”.
 
At the beginning of June, Tegnell conceded that Sweden should have imposed more restrictions to avoid having such a high death toll. 
 
The US and UK mindset

Compared to the responses described above, the US and UK were slow to implement testing, late to acquire essential equipment, gave confusing public health messages and delayed introducing stringent lockdowns and social distancing. For example, in mid-March, when borders were being closed and mass quarantines enforced across Europe, the US government was failing to establish a clear and focused response to the outbreak. By the time the US President declared a national emergency, several states had introduced lockdowns, universities had shifted to online learning and churches had begun to close. At the same time, schools in England largely remained open and the UK government was pursuing a strategy of exposing its population to the coronavirus in the expectation that citizens would develop a “herd immunity”. As of May 31, the US with a population of 328m, had confirmed 1.83m cases and 106,000 deaths, and the UK with a population of 67m, had 276,000 cases and 39,045 deaths.
 
Signs of danger ignored

Neither the US nor the UK government appeared to have been influenced by well publicised signals of pending dangers, which included: (i) CoVID-19 being a highly contagious ‘novel’ coronavirus without either a therapy or a cure, (ii) around January 23, after the discovery of the outbreak and before the lockdown of Wuhan, the city in China where the virus originated, some 5m people left the city and were potential super spreaders, (iii) by February 4, the coronavirus had spread to 24 countries, (iv) also on February 4, China had opened the first of two mega hospitals in Wuhan, both built from scratch in a couple of weeks specifically to cater for patients affected by the fast-spreading coronavirus. Together, the two hospitals had a 2,600-bed capacity and were staffed with over 3,000 health professionals.
 
Mixed messages

Inside the US messages about CoVID-19 were mixed. Main media outlets reported the acceleration of the virus internationally and state governors independently started to take emergency actions. Notwithstanding, on February 26, at a White House briefing, President Trump urged Americans to take the same precautions for coronavirus as they would for normal flu, and US Health and Human Services Secretary Alex Azar advised that the coronavirus only posed a low risk to the American public. On February 25, the Centers for Disease Control and Prevention (CDC) confirmed that there were 60 CoVID-19 cases in the US and warned Americans that “it's a question of when, not if” the virus, which had killed thousands, would spread within the US.
 
Convinced of a rapid V-shaped recovery

In late February, in tune with White House messaging, many US business leaders from sectors not seriously affected by CoVID-19, were convinced that the coronavirus outbreak would be a relatively short-lived regional issue, concentrated in China with some limited transmission through supply chains to other parts of Asia, Europe and the US. They believed the outbreak would only have a temporary impact on global GDP and trade and weigh modestly on US business activities in Q1 2020. Although it might be difficult to contemplate now, in late February some US business leaders were suggesting that their companies and the American economy would bounce back in Q2 2020 after a modest V-shaped dip.
 
Such optimism might have been influenced by the SARS outbreak, which also originated from China, spread to 37 countries, infected more than 8,000 people and killed about 800. The impact SARS was to reduce China’s GDP growth by about 1% and it only had a limited effect on world GDP and trade. Although the SARS epidemic did not register much with US business leaders, it prompted Beijing to overhaul its healthcare system and prepare China for another potential virus epidemic. After SARS China invested in systems for disease surveillance and reporting, as well as epidemic prevention and control. Centres for disease control were built across the country and public insurance programmes were expanded to provide affordable care for the rural population. Arguably, this strengthened China’s preparedness for its response to CoVID-19.
 
By contrast, the US and UK did not appear to perceive a threat of a pandemic as serious. In May 2018, President Trump disbanded the US Global Health Security and Biodefense unit responsible for pandemic preparedness, which was established in 2015 by Barack Obama’s National Security Advisor. The UK did something similar. According to Professor Sir Ian Boyd, the UK’s Chief Scientific Adviser between 2012 and 2019, the nation’s biological security strategy, which Boyd partly wrote and published in 2018 to address the threat of a pandemic, was not properly implemented because of a lack of resources.
 
Commercial impact

As a consequence, on March 11, when the World Health Organization (WHO) declared the coronavirus CoVID-19 as a pandemic the US and UK were unprepared. The WHO pointed to Europe as the “epicentre” of the outbreak and, by the end of March, the outbreak had a significant effect on most industries in the developed world. Transportation, manufacturing and wholesale trade sectors were substantially affected by disrupted supply chains and travel restrictions. In many countries retail and hospitality sectors experienced sharp falls in demand and were closed. However, sectors differed in their ability to respond flexibly to supply disruptions and falls in demand. For example, business as usual continued for many professional services if their employees were able to work from home.
 
Impact on healthcare

The impact on healthcare was mixed. Demands on hospitals increased significantly as they shifted their resources and efforts to treating CoVID-19 patients. Policy responses were aimed at managing the increased capacity demands on hospitals by ‘flattening the curve’ of infection. The impact of the coronavirus outbreak on the MedTech sector was bifurcated. The vast and increased demand for critical care devices and personal protective equipment (PPE) significantly advantaged some manufacturers, while others, particularly orthopaedics, were disadvantaged as hospitals dedicated capacity to treating infected coronavirus patients and deferred non urgent surgeries. Sector forecasts suggested a reduction in medical device use in the Q1 and Q2, and a moderate recovery in the second half of 2020. But this hinged on successful efforts to halt the virus' spread. The global economic slowdown and the shift in healthcare resources toward fighting CoVID-19 dented MedTech sales and triggered a hit to their stock valuations.

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CoVID-19 weakens the ‘Western brand

Some commentators perceive the CoVID-19 crisis as a test of the competing claims of liberal and illiberal states to better manage significant social and economic shocks. According to Stephen Walt, Professor of international affairs at Harvard University's John F. Kennedy School of Government, the slow and diffident responses to the outbreak from US, UK and some other European governments could potentially weaken the dominance of the Western brand, and “accelerate the shift of power and influence from west to east”.
China building on the response to SARS

Despite China’s endeavours to be ready for a pandemic after the SARS outbreak, CoVID-19 exposed cracks in China’s preparedness, which Beijing swiftly sought to fix. This included enhancing the nation’s healthcare system’s cost management by further centralizing procurement, purchasing drugs in bulk and implementing a two-invoice policy to eliminate layers of bureaucracy in the nation’s distribution channels. Beijing also encouraged product innovation from local and foreign companies by fast-tracking approvals for medicines and medical devices. And, like many other countries, China increased its digitalization strategies by accelerating the integration of big data, artificial intelligence, telemedicine, online pharma retail and more. The coronavirus impact in China and elsewhere in the world prompted a massive shift in patients and doctors using Internet-based options for diagnosis and treatment. This shift to digital necessitated by the coronavirus outbreak is well positioned to become the ‘new normal’, which could help healthcare providers, hospitals, health systems and clinicians optimise their use of resources.
 
G7’s response to CoVID-19

Between March and April, G7 nations (Canada, France, Germany, Italy, Japan, the UK and the US) injected US$2.5tn of new money into financial markets through quantitative easing and liquidity programmes to help nations recover from the economic crisis caused by CoVID-19. Notwithstanding, only about US$1 in US$10 lent by British banks went to non-financial service companies. Most of the new credit supported financial trading. A similar pattern occurred in other G7 countries. As these nations navigate their way out of the crisis, there is little evidence of any industrial strategy being linked the CoVID-19 shock. For economies to recover, they will need financial markets to do something similar to what they did following WWII when banks worked closely with governments and used the increased liquidity for committed long-term financing that created jobs, enhanced productivity and stimulated innovation.

Interestingly, on May 30, President Trump said he will postpone the G7 meeting planned for August at the White House. He called the current group’s format , “very outdated”, suggested that it does not properly represent "what's going on in the world" and said its membership should include Russia, Australia, South Korea and India.
 
The pandemic is not over

Compared with G7 nations, China has opted for a more strategic approach to its recovery from the pandemic. Beijing has put the prevention and control of the CoVID-19 crisis as the keystone of a national strategy. Significantly, Premier Li Keqiang, did not use his annual report to China’s National Legislature on May 29 to claim victory over CoVID-19. Instead he stressed that, “The pandemic is not over” and outlined Beijing’s plans for continued vigilance against the coronavirus, which, Li said, “is a core thread in determining everything from macro-level strategy to micro-level policy for the foreseeable future in China”. Beijing committed a ¥1tn (US$138bn) rise in its fiscal deficit and ¥1tn of special governments bonds to its CoVID-19 recovery strategy, which is dedicated to: (i) securing jobs, (ii) maintaining and increasing people’s livelihoods, (iii) developing businesses, (iv) securing food and energy, (v) developing and maintaining stable industrial and supply chains, and (vi) reducing government red tape.
 
CoVID-19 strengthens the US$

Beijing’s coronavirus recovery strategy does not guarantee that China will evolve stronger than the US from the crisis. Indeed, the US may surface in better shape than analysts suggest. This is because of the strength of the US$, which remains the world’s reserve currency and is perceived as a relatively safe asset in times of crisis. The CoVID-19 crisis reinforced the US$’s strength and therefore it seems reasonable to suggest that the coronavirus outbreak may not do as much damage to the US economy as some observers suggest. Walt’s prediction, mentioned above, that CoVID-19 will accelerate the shift of power and influence from West to East will depend on whether: (i) the US successfully restarts its economy and avoids a resurgence of the coronavirus, and (ii) the US maintains its ‘America first’ approach to the pandemic or changes to its natural global leadership position, which it assumed after WWII.
 
US suspends payment to the WHO

On March 26, after a virtual G20 summit, there were encouraging signs when a joint statement said that, “Combatting this pandemic calls for a transparent, robust, coordinated, large-scale and science-based global response in the spirit of solidarity. We are strongly committed to presenting a united front against this common threat”. Despite this pledge to cooperate, little cooperation followed, and the pandemic became a theatre for a wider disagreement between the US and China. On April 20, President Trump suspended US payments to the WHO in protest at what he regards as the body’s China-centric approach, reflected, by what he suggests is the WHO’s failure to challenge China sufficiently over the origins of the CoVID-19 outbreak. On May 29, Trump said, “We will be today terminating our relationship with the World Health Organization and redirecting those funds to other worldwide and deserving urgent global public health needs”. In the near-term, before the US presidential election in November, it does not look that the US will change its ‘America first’ strategy.
 
Takeaways

CoVID-19 has created an unprecedented global crisis. Governments throughout the world responded to the crisis by closing their boarders, implementing stringent lockdown restrictions and used wartime rhetoric to rally their citizens. While this temporarily lowered the rate of infection it is not a permanent solution. Two significant takeaways from the coronavirus crisis are: (i) not even the riches and most technologically advanced nations with state-of-the-art healthcare systems were able to protect their populations and (ii) only by turning outwards and embracing effective international cooperation will nations protect their citizens and safely exit the CoVID-19 crisis.

#coronavirus #coVID-19 #pandemic #coVID-19outbreak #lockdown
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The HealthPad team extends its sincerest best wishes to you, your families and loved ones during these unprecedented times caused by the coronavirus CoVID-19 pandemic. We trust that you all stay safe and well.

To everyone working long and stressful hours on the frontline of healthcare; thank you for the sacrifices you’re making every day to help others in their moments of need. Your dedication, commitment and courage have our deepest gratitude and admiration.

Also, our heartfelt thanks go to all key workers who are unselfishly providing essential services, which are helping all of us through this coronavirus outbreak. Your resolution and mettle make a huge difference to our daily lives and we hold you in the highest esteem.

 

#coronavirus #CoVID-19  #frontlinehealthcareworkers #keyworkers #healthcare

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  • The coronavirus CoVID-19 has created the greatest health-cum-economic-cum-societal crisis in history and put unprecedented pressure on overstretched and unprepared healthcare systems
  • Before the coronavirus outbreak, primary care in England already was in crisis, fuelled by an aging population, a large and increasing demand for its services and a shrinking supply of health professionals
  • In 2019, before the outbreak, 75% of primary care doctors (GPs) across 540 clinics in England were over the age of 55 and nearing retirement and a large percentage of newly trained GPs were seeking employment abroad
  • Patients who could not get GP appointments used A&E departments as convenient drop-in clinics for minor ailments, which significantly increased healthcare costs and burden
  • For decades successive UK governments have tried in vain to transform the nation’s primary care services predicated upon face-to-face patient-doctor consultations
  • Several well-funded long-term national plans advocated increased digitization of some routine primary care services
  • But before the coronavirus outbreak only 1% of all primary care consultations were online
  • What these national plans could not achieve in decades appears to have been achieved in days by the UK’s NHS’s response to the coronavirus outbreak
  • Today, millions of patients in England are having face-to-face appointments with their GPs replaced by telephone or video consultations
  • Could CoVID-19 transform the UK’s traditional primary care model?

 

Introduction
 
The UK’s National Health Service’s (NHS) response to the coronavirus CoVID-19 outbreak might improve the nation’s crisis ridden primary care service. This became evident in March 2020, when the UK government ordered all citizens except key workers to stay at home. At the same time, NHS England announced its ‘battle plan’ for CoVID-19, which recommended that England’s 7,000 primary care clinics start conducting as many remote consultations as soon as possible.  In a matter of days, millions of patients had face-to-face appointments with their GP replaced by telephone or video consultations. If this shift to online consultations becomes permanent then the NHS’s response to the coronavirus would have achieved in days what well-funded national healthcare plans, such as the NHS Digital First Primary Care drive, could not achieve in decades.
 
Future healthcare is digital
 
For years, the benefits of online doctor-patient consultations have been advocated by  Devi Shetty, a world-renowned heart surgeon and  founder and chairman of Narayana Health, one India’s largest hospital groups.  According to Shetty, “The next biggest thing in healthcare is not going to be a ‘magic’ pill, a faster scanner or a new operation but information technology (IT). IT will dramatically change the way a health professional will interact with a patient. Every step of patient care will be informed by a protocol embedded in a smartphone. This will make healthcare safer for the patient and remove a lot of traditional dace-to-face healthcare activities and shift healthcare away from the clinic and into the home. Doctors and patients don't need to be together; they could be in their respective homes and effective consultations could take place online.” (see video below)
 
The next ‘big thing’ in healthcare
 
The coronavirus CoVID-19
 
In December 2019, initial reports of a new coronavirus - CoVID-19 - emerged  when patients from Wuhan, the sprawling capital city of China’s Hubei province, which has a population of some 11m, presented with pneumonia of unknown origin. By December 2019 the virus had spread to other countries and on 11th March 2020, the World Health Organization characterised the outbreak as a pandemic. CoVID-19 is an illness caused by a member of the coronavirus family that has never been encountered before but is believed to come from animals.There have been other coronaviruses. For example, severe acute respiratory syndrome (Sars) and Middle Eastern respiratory syndrome (Mers) are both caused by coronaviruses that came from animals. In 2002, Sars spread virtually unchecked to 37 countries, causing global panic, infecting more than 8,000 people and killing about 800, but it soon ran itself out. Mers first emerged in 2012, cases of which have been occurring sporadically since. Mers appears to be less easily passed from human to human, but has greater lethality, killing 35% of about 2,500 people who were infected. CoVID-19 is different to Sars and Mers in that the spectrum of disease is broader, with around 80% of cases leading to a mild infection. There may also be many people carrying the disease and displaying no symptoms, making it even harder to control. CoVID-19 affects your lungs and airways and can cause pneumonia. So, people with an  inflammatory lung disease that causes obstructed airflow from the lungs, such as asthma and chronic obstructive pulmonary disease (COPD), are particularly vulnerable; as are people with weak immune systems, which make them susceptible to infections that might be more severe or harder to treat. In January 2020, China’s national health commission confirmed human-to-human transmission of CoVID-19, and there have been such transmissions in countries throughout the world. Those who have fallen ill are reported to suffer a general feeling of being unwell, fever, dry cough, tiredness, breathing difficulties and a loss of taste and smell. In roughly 14% of cases the virus causes severe disease, including pneumonia and shortness of breath. In about 5% of patients it is critical, leading to respiratory failure, septic shock and multiple organ failure. As this is viral pneumonia, antibiotics are of no use. The antiviral drugs we have against flu will not work. Recovery depends on the strength of your immune system. Many of those who have died were already in poor health. Initially, scientists were challenged to accurately assess how dangerous CoVID-19 was because there were inadequate data. A challenge  to  collecting data was because of a shortage of tests and also because people who had contracted the coronavirus were emitting, or “shedding,” infectious viruses early in the progression of the illness; sometimes before they develop symptoms.

The 1918 Spanish Influenza 
remains the most devastating virus in modern history. The disease swept around the globe and is estimated to have caused between 50m and 100m deaths. A cousin of the same virus was also behind the 2009 swine flu outbreak, thought to have killed as many as 0.58m. Other major viral outbreaks include the Asian flu in 1957, which led to roughly 2m deaths and the Hong Kong flu, which killed 1m people 11 years later. 

 
In this Commentary
 
This Commentary is produced by HealthPad, which is an online health solutions company. (see below). We begin the Commentary by briefly describing the underlying reasons for the UK’s primary care crisis, which include: (i)  the changing and aging population and the consequent increased demand for healthcare, (ii) the shrinking supply of health professionals, and (iii) failing national initiatives to improve the provision of primary care. We then draw attention to some well funded national plans, whose intentions have been to harness the power of information and digital strategies to reform and improve primary care services in England. We also cite research, which suggests that these plans have failed. The Commentary briefly describes a number of innovative online healthcare solution companies, (HealthPad is one).  The majority of these are private initiatives, which have taken advantage of the UK’s high smartphone penetration rates and advanced wireless networks to enter the UK’s healthcare market with an intention to transform the sector. Notwithstanding, to-date the overall impact of these companies has been marginal, due in part, to the general resistance of private enterprises playing a significant role in England’s public NHS, which offers free healthcare to all citizens at the point of care. However, they represent a nascent UK online healthcare solutions market, which is well positioned to benefit from the nation’s response to the coronavirus outbreak, which has forced more primary care services to be delivered online. To increase their footprint these companies, which are largely driven by technology, will need to become more strategic and consolidate. And this will take time. We conclude the Commentary by looking to China and WeDoctor to understand the potential that online services can make to the delivery of healthcare in England. WeDoctor is a Chinese mobile app launched in 2010 to help patients book doctor appointments. Over the past decade it has added more functions to help unclog China’s fragmented and bureaucratic healthcare system and has become a US$5.5bn healthcare company, which connects some 210m registered users with 360,000 doctors.
 
UK’s primary care crisis
 
There are three drivers to the UK’s primary care crisis: (i) the changing and aging population, which increases the demand for healthcare, (ii)  the shrinking supply of healthcare professionals to a point where GP workloads are becoming unsafe, and (iii) failing national initiatives to improve the provision of primary care. Let us briefly describe these.
 
Changing and aging population
 
The UK’s population is changing and aging, which is fuelled by improvements in life expectancy and a decrease in fertility. According to the UK’s Office of National Statistics, in 2016, there were 12m UK residents aged 65 years and over, representing 18% of the total population. 25 years before, in 1991, there were 9m, accounting for 16% of the population. By 2040, it is projected that there will be an additional 8m people aged 65 years and over in the UK: a population roughly the size of present-day London, which will account for 25% of the total population.
 
A report by Deloitte,  a consultancy, suggests that as people age so their propensity for illness increases and more than a quarter of the UK’s population of some 66m have long-term chronic illnesses. This places a significant extra burden on the nation’s overstretched primary care services by utilizing about half of all GP appointments. Deloitte’s analysis is supported by a British Medical Association’s 2019 GP Patient Survey, which found that GP clinics are now caring for 0.72m more patients than they were in 2018. Findings of a 2016 report by the UK’s Royal College of General Practitioners (RGCP), suggest that GPs see 1.3m patients a day and do more than 370m consultations annually: 60m more than in 2010. A research study on GP productivity carried out by the King’s Fund and also published in 2016, suggested that between 2010 and 2015 the total number of telephone consultations increased by 15%, but still only accounted for 1% of all patient-doctor consultations.
 
Shrinking supply of GPs
 
As the UK’s population has grown and aged and the consequent demand for healthcare has increased, so there has been a sustained fall in the number of GPs. This  dynamic is described in a Nuffield Trust report published in May 2019, which confirms the findings of a joint report from the Institute of Fiscal Studies and the Health Foundation for the NHS Confederation, which concluded that, “The fall in GPs per person reflects insufficient numbers previously being trained and going on to join NHS England, failure to recruit enough from abroad and more GPs leaving for early retirement”. As to the future, a  2019 report by three leading think tanks - the Nuffield Trust, the Health Foundation and the King's Fund - predicts that GP shortages in England will almost triple to 7,000 by 2024. According to NHS Statistics, Facts and Figures, currently there are just over 42,000 GPs working in England, down by nearly 1,500 since 2016.
 
Failure to stop or slow these trends means today, primary care services in England struggle with staff shortages and a rising demand for care. A 2019 Pulse Magazine survey found that  GPs in England are seeing more patients than is safe. A probe undertaken by The Times in 2019 suggested that the  national shortage of GPs has left some surgeries with one permanent doctor caring for as many as 11,000 patients and one in 10 GPs are seeing up to 60 patients a day, double the number considered safe.
 
GPs across the UK work an average 11-hour day. In that time, they typically see patients for 8 hours and spend the other 3 on administrative tasks such as checking test results and reading letters sent by hospitals.  A 2019 British Medical Association survey found that more than 80% of GPs said the pressure to attend to multiple tasks at once meant they were unable to guarantee safe care, while 91% said excessive workload was the main reason the NHS was struggling to recruit enough staff. The situation has resulted in patients having to wait longer - up to three weeks - for a GP consultation. It seems reasonable to suggest that GPs with too many patients and using traditional face-to-face delivery methods will fail in their duty of care, which obliges them to inform patients about their health and reach shared clinical decisions about treatments. This requires that patients understand their condition/s and are well informed. In many cases, a 10-minute  face-to-face GP consultation might not be the best way to achieve this.
 
Failing national initiatives to improve primary care
 
Subsequent UK governments have struggled to reduce the primary care crisis with well funded national plans. In 2019, the British Medical Journal published findings of a survey to report UK GPs’ views and experience of national healthcare initiatives introduced in England to address the workforce crisis in general practice. The survey was conducted in the same region as a similar survey undertaken in 2014. This allows for a comparative analysis to see how GPs’ views have changed over time. Findings confirm that primary care in England remains in crisis and suggest that numerous national initiatives to improve general practice are perceived by GPs as, “reactive in approach”. To reduce the primary care crisis, respondents suggested, “more GPs and better education of the public". 
 
The UK’s NHS
 
Healthcare in the UK is mainly provided by the National Health Service (NHS), which is a vast public institution funded largely from general taxation to the tune of some £134bn (US$161bn) a year. Created in 1948, the NHS  provides free health services at the point of care for everyone living in the UK and has become the largest single payer health system in the world, and the biggest employer in the UK with 1.2m full time equivalent (FTE) workers, which is the fifth-largest workforce in the world. NHS England is a vast bureaucratic and fragmented organisation, which has proven difficult to change. Private provision of NHS services has always been controversial, even though some services, such as dentistry, optical care and pharmacy, have been provided by the private sector to the NHS for decades and most GP practices are private partnerships. It is challenging to determine how much the NHS spends each year on the private sector because central bodies do not hold detailed information on individual contracts with service providers, especially where these contracts may cover relatively small amounts of activity and spending. Notwithstanding, estimates suggest the share of the NHS’s total revenue budget that is spent on private providers is about 7.3%. 

National plans to improve the NHS
 
The planning and authorising of NHS services is the responsibility of regional Clinical Commissioning Groups (CCGs). Although CCGs are constantly changing because of mergers, as of 2019, there were 191 CCGs in England supporting about 7,000 primary care clinics, some 42,000 GPs and about 15,800 FTE nurses who work in GP clinics, and 1,257 hospitals, which include NHS Trust-managed hospitals and private hospitals that provide services to the NHS. In total, the NHS employs around 150,000 doctors  and over 320,000 nurses and midwives.
 
Successive UK governments have been aware of the impact of technological advances, changing healthcare needs and societal developments on healthcare and have introduced a succession of well-funded national plans to change and improve the NHS. For example, in June 2018, the UK’s Prime Minister announced a new five-year funding settlement for the NHS that amounted to an extra £20.5bn (US$25.2bn) between 2019 and 2024, which represents a 3.4% real average annual increase.
 
NHS long term plan to transform primary care
 
To unlock the funding, national bodies were asked to develop a long-term plan to help the NHS cut costs and improve services. The suggested plan articulated the need to integrate care in order to meet the needs of a changing population and was in line with the Forward View, a planning document published in 2014 and the General practice forward view,which was first published in 2016 and updated in subsequent years. The long-term plan committed the government to an extra £2.4bn (US$3bn) a year to speed up the transformation of primary care and suggested GP clinics join together to form networks typically covering 30,000 to 50,000 patients and provide them with multidisciplinary integrated care. The plan also suggested ‘significant changes’ in the existing performance management and payment of NHS GPs [the Quality and Outcomes Framework (QOF)] in order to encourage more personalised care.
 
NHS long term plans and private online healthcare solution companies have delivered little change
 
Three of five principal objectives of the latest NHS long term plan are to: (i) “give people more control over their own health and the care they receive”;  (ii) “increase the contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes”, and (iii) “provide more convenient access to services and health information for patients”.

The plan emphasises the importance of developing digital services, and recommends that within five years, all patients should be able to access GP consultations via a telephone or online. This goal is supported by NHS Digital, which is the national information and technology partner to the UK’s health and social care system. Its mission is to harness the power of information and technology to improve healthcare. Over the past decade there has been an increasing number of innovative online private  healthcare solutions companies entering the market. (see below). Notwithstanding, these and the NHS’s well-funded national plans, have failed to dent the primary care crisis by slowing the vast and escalating demand for healthcare and reversing the shrinking supply of healthcare professionals. So, for the past two decades at least, the NHS has tended to operate on the cusp of a crisis.
 
The death of distance
 
According to Deloitte, the UK has more than 90% smartphone penetration. The main driver of high smartphone adoption rates is the take-up among older age groups. By 2023 smartphone ownership among 55-to-75-year-olds will reach 85% in the UK, and the difference in smartphone penetration by age will disappear. Further, the UK’s smartphone market has seen a greater variety of choice of models and the introduction of faster and more reliable wireless networks. This has benefited the online private healthcare solution companies, which have entered the UK market to provide varying degrees of qualified online healthcare information, consultations, networking opportunities, triage and Q&A. According to Shetty, “A doctor only needs to touch a patient if s/he is going to operate on that patient. If a doctor doesn’t need to operate, a doctor-patient consultation can take place remotely. For a patient-doctor communication distance doesn’t matter.” (see video below)
 

 A doctor only needs to touch a patient if s/he is going to operate on that patient
 
Innovative online healthcare solution enterprises
 
The new online healthcare solution enterprises are a combination of private, public and charitable initiatives, which are well positioned to contribute to the transformation of the UK’s traditional primary care model and include: Babylon Health, which provides remote consultations with doctors and healthcare professionals via text and video; BioBeatsa workplace wellbeing platform designed to empower and improve mental health; Docly, a digital messaging healthcare service, which is a spin-off of Min Doktor; Doctorlink, which partners with payers, healthcare professionals and pharmacists to provide a 24-7 platform for NHS patients to assess symptoms; DrDoctor, a patient engagement platform, which enables patients to book, change and cancel their appointments; EggPlant, a software testing and monitoring company, which helps to streamline patient activities; Dr Fox, an online primary care clinic and pharmacy service; Gogodoc, an online GP video consultation service with possible follow-up home visits; Healthcare Communications UK, which provides appointment management software and patient experience surveys; HealthPad, an online platform that manages and distributes healthcare video information between health providers and patients in order to improve outcomes and cut costs, and has accrued a proprietary content library of over 6,000 short videos contributed by leading clinicians that address peoples FAQs across some 30 therapeutic pathways, (HealthPad is the publisher of this Commentary).  HealthTalksOnline, an events and community portal for health; HealthUnlocked, a social networking service that offers peer support to help people manage their health; Healum provides healthcare professionals with a software, which enables them to support and motivate their patients to better manage their conditions; LIVI, provides GP video consultations; Medshra platform for medical professionals to discover, discuss and share clinical cases and medical images; Microtest Health, a health informatics company that provides practice management systems for NHS GP surgeries. MSKnote Limited creates clinical applications for healthcare professionals and patients with a focus on musculoskeletal conditions; MyWay Digital Health provides advice and solutions to help patients better manage diabetes; NHS.uk/conditions provides online text-based information and advice about medical conditions; NHS 111, a free-to-call medical helpline; the Now Healthcare Group, a GP video consultation platform and tele-pharmacy; Patient Access, which started by enabling patients to book GP appointments online and order repeat prescriptions and has evolved to allow patients to connect with their GPs remotely and access their medical records online; Patientinfo provides patients and health professionals with online health information. PatientAccess and Patientinfo are subsidiaries of EMIS Health, a leading supplier of  software used by NHS England; Patients Know Best, a social enterprise, which provides patients with access to their medical records and information about treatments; PatientsLikeMe, an online service that helps patients find people with similar health conditions in order to take actions that are expected to improve outcomes; Push Doctor, an online video consultation service; SaySo Medical is a digital communications agency, which connects people in order to improve their health; SystmOne, a centrally hosted computer system that provides primary care professionals with electronic patient health records in real time at the point of care; uMotif, a platform that captures electronic patient-reported outcomes data across a range of conditions and works with pharmaceutical companies to measure patient’s health, outcomes and experience; Unminda workplace mental health platform designed to  empower organisations and employees to improve their mental wellbeing; Visiba Care, a digital solutions company, which provides communication and administration software for healthcare practices; VisionHealth provides NHS primary care professionals with software solutions; VisualDX provides clinical decision support systems to enhance diagnoses and therapeutic decisions in order to improve patient safety; WebMD, an online publisher of healthcare news and information, and Zava, an online GP and pharmacy service.
 
 Technologically heavy and strategically light
 
Despite a significant number of online healthcare solution enterprises entering the market and the fact that some provide services to millions of people in the UK, this market segment is in its infancy and fragmented. All the initiatives mentioned above have been advantaged by the NHS’s response to the coronavirus outbreak. Notwithstanding, to permanently increase their footprint and significantly influence primary care in England, barriers to private enterprises and to online services will need to be reduced; and private companies in this segment will need to act more strategically and consolidate.
 
Most of these online healthcare service providers are technologically heavy and strategically light. For private companies in this market to grow and increase their influence on the NHS they will need to increase their focus on profitability and scale, which will require them to become more strategic and develop merger-integration skills. To become a dominant player, a company will have to successfully consolidate. Speed and merger competence are paramount. Companies that capture critical ground early and move up the consolidation curve the fastest will be successful. Enterprises that are slow to consolidate will become acquisition targets and disappear. Companies that stay out of the consolidation contest altogether will not survive.

A Chinese example
 
History has shown that many short-term emergency measures have a tendency to  become permanent fixtures. Thus, the UK’s response to the coronavirus CoVID-19 outbreak might permanently reduce the barriers to moving routine primary care tasks to innovative private online enterprises.
 
In an attempt to fully appreciate the potential of increasing online primary healthcare services in England, consider WeDoctor, a Chinese mobile app launched in 2010 by artificial intelligence expert Jerry Liao. Originally called Guahao (Mandarin for “booking”), WeDoctor started as a simple booking platform that made it easier for patients to make appointments with doctors. From these humble beginnings WeDoctor grew by adding extra functions such as reminders for regular medical checks, screening, prescriptions and online diagnoses and consultations. This helped to unclog China’s fragmented and bureaucratic healthcare system and made quality healthcare more accessible to the average person.
 
WeDoctor secured backing from Tencent Holdings, a Chinese multinational conglomerate, Sequoia Capital, the Goldman Sachs Group and the insurer AIA Group. In 2018, the company raised US$0.5bn in a private financing round at a valuation of US$5.5bn. Today, WeDoctor has more than 210m registered users mainly in China for its online appointment booking, prescription and diagnosis services and is linked to about 3,200 hospitals and 360,000 doctors. In March 2020, at the height of the CoVID-19 pandemic, it was reported that, in the latter half of 2020, WeDoctor intends to raise HK$1bn in an IPO on the Hong Kong Stock Exchange at a valuation of HK$10bn.
 
Although NHS England is much smaller than China’s healthcare provision, it is similarly fragmented and bureaucratic. The UK online solutions enterprises described in this Commentary have significant potential simply by helping to reduce GPs large and increasing burden of administration while increasing the connectivity between patients and GPs. This will help GPs to concentrate on what they have been trained to do and improve healthcare for people in most need.
 
Takeaways
 
Over the past two decades, legacy primary care systems and attitudes in the UK have slowed the uptake of online healthcare solutions. Notwithstanding, the NHS’s response to the coronavirus CoVID-19 outbreak might prove to have helped to transform the UK’s traditional face-to-face primary care model by making GPs deliver some of their services online. In a recent interview with the New York Times, Dr Bruce Aylward, Assistant Director-General of the World Health Organization, stressed how the Chinese had responded to the coronavirus outbreak by significantly increasing the amount of medical care the nation provides online.  In light of the discussion in this Commentary, be minded that in Mandarin the word “crisis” is denoted by two characters: 危机, one means ‘disaster’ and the other means ‘opportunity’.
 
 
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