Are patients taking their medications correctly, and are the medicines working? A handful of digital health startups tries to make it easier to tell — say, by embedding a tracking system into pills they swallow.
Only 25% to 50% of patients worldwide take medications correctly, and in the U.S., roughly 125,000 people die annually from not correctly taking their prescriptions, according to a 2018 study led by Leah Zullig, a health services researcher at the Duke University School of Medicine.
Failure to take prescribed medicines also increases costs to the healthcare system, by about $300 billion annually, Zullig estimates. Jonathan Watanabe, an associate professor of clinical pharmacy at UC San Diego’s Skaggs School of Pharmacy & Pharmaceutical Sciences, says that number would likely be even higher if you included what it costs hospitals to treat symptoms that arise from improper medicine intake (for example, patients with high blood pressure who have strokes as a result of not taking their medicines)—more than $500 billion annually, or 16% of U.S. healthcare costs, he estimates.
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For the most part, the responsibility has been in the hands of the patient. Think pill boxes marked with the days of the week, or their high-tech versions—apps, like Medisafe and CareClinic, that help users self-report their own intake and schedules. These reminder devices don’t go far enough, say some doctors, because they fail to address a very human fault that patients report as their primary reason for not taking their medication: forgetfulness.
We Are Our Own Prince Charming
“We need to take responsibility for our own health and care, but when it comes to drug-taking and medication use, that may not be sufficient,” says Dr. Niteesh K. Chouhdry, a professor of medicine at Harvard Medical School and executive director of the Center for Healthcare Delivery Sciences at Brigham & Women’s Hospital in Boston. “We need to leverage these devices in a way that closes the loop—doctors to pharmacists to patients back to pharmacists.”
Proteus Digital Health, a Redwood City, California-based tech health startup, hopes to create that loop. Founded in 2004 by Andrew Thompson and Dr. George Savage, the company makes a 1 millimeter sensor—“the size of a poppy seed or grain of sand,” says Thompson—that is embedded in medications, which are then swallowed.
The sensor, made of “elements found in a typical diet,” including magnesium and copper, says Thompson, will turn on when it contacts a patient’s stomach acid. It then sends a signal a the palm-size patch that patients wear on their skin. The patch, which also tracks physiological signs like steps, rest and heart rate, then sends information to a smartphone app for patients and the desktop browser portal that doctors use.
The idea for the system, called Proteus Discover, came to Thompson during an American Heart Association conference in 2003. Thompson, who had previously started two medical device companies with Savage, including the publicly traded FemRx, which was acquired by Johnson & Johnson for $22 million in 1998, noticed that none of the companies presenting at the conference were doing anything with digital technologies.
“Silicon and software was innovating every other industry at the time except for pharma,” Thompson says. So he brought his idea for a medicine that communicates with a computer to Savage.
“George looks at me and says, ‘That is the stupidest idea you’ve had in your entire life.’ And then we began to argue,” Thompson says.
In 2017, the FDA approved an antipsychotic drug with Proteus technology, the agency’s first-ever approval for a medicine with digital ingestion tracking system. Abilify MyCite, the drug made with Tokyo-based Otsuka Pharmaceutical, treats schizophrenia, bipolar disorder, depression and Tourette syndrome.
The company has raised $420 million in venture capital funding from investors including Novartis Venture Fund and Kaiser Permanente Ventures at a $1.5 billion valuation. Otsuka, which has a special focus on mental health drugs, announced in October 2018 an $88 million investment in Proteus to continue developing other medications that use the tech-health venture’s ingestible sensors. More than 1,000 patients have used the pill-tracking system, amounting to 195,000 pill ingestions, says the company.
EtectRx, Keratin Biosciences
Other companies have sprung up in the drug delivery space, including etectRx, a Newberry, Florida, health-tech startup with a similar digital health system model. Instead of working with a pharmaceutical company to embed its sensors in a pill, etectRx creates an empty gelatin capsule with an embedded wireless sensor. Its capsule has not received FDA clearance yet, but it can be used in clinical studies that have been approved by the agency’s Institutional Review Board, a committee that reviews and monitors scientific research.
Keratin Biosciences (formerly Microchips Biotech and KeraNetics before the two merged in July 2018) wants to improve medication intake by getting rid of human error altogether. Instead of a pill, this Lexington, Massachusetts, company makes a microchip with hundreds of sealed compartments, each of which can store up to 1 milligram of a drug.
The chip, which originated in a lab at the Massachusetts Institute of Technology, can be activated by a wireless signal that triggers the compartments to release the drug, based on a preprogrammed dosing schedule.
Digital health startups must figure out how to get the new drug delivery methods they are delivering to patients and consumers in a scalable way, which will require collaboration and a commitment from Big Pharma. “The core thing we want the pharmaceutical industry to understand is that we want to integrate silicon software into the definition of their products in order to make information and data a part of what they do,” Thompson says.
Then there is the matter of consumer hesitance about swallowing hardware that records private activity. While these inventions are meant to help patients, the monitoring aspect has raised privacy concerns from consumer advocates who worry that the information will eventually be shared not just with doctors but with insurers who want to raise premiums or even employers who want to know what drugs a job candidate is taking.
“Security of the data is very important, but in medicine, privacy can be lethal,” Thompson argues. He says that the main issue is not so much privacy but whether companies make it clear to patients where their data is going. “People are happy to share information and data if they know and understand exactly what it is being used for.”
Proteus can claim its smart pills are effective, but it’s still early for most startups that aim to improve the way patients take their medicine.
“This is a tough problem to fix,” says Choudhry from Harvard. “It’s all about forgetfulness, and that is a complex and, frankly, normal behavior.”
-Angel Au-Yeung; Forbes Staff
Cure For Counterfeit Drugs?
Blockchain technology is also revolutionizing supply chains in the pharmaceutical industry, in the process, helping track fake medicines.
From genomics to robotics, technology is truly revolutionizing the healthcare sector. And while it’s easy to become consumed by exciting, futuristic trends like artificial intelligence (AI) diagnosis, digitized patient records and 3D-printed medical tools, technology is also transforming the pharmaceutical industry. How medication is prescribed, dispensed and administered is big business with McKinsey predicting the value of Africa’s pharmaceutical industry to be $65 billion in 2020.
But fake drugs are an ongoing and complex issue – they can cause death, have unknown side-effects, fail to treat illnesses, and sometimes even add to the spread of disease. According to World Health Organization (WHO) statistics, 42% of detected cases of falsified (or substandard) pharmaceuticals occur in Africa – reports estimate that between 72,000 and 169,000 children die each year from pneumonia because of counterfeit antibiotics while fake malaria drugs cause an additional 64,000 –158,000 deaths every year in sub-Saharan Africa. Both antimalarials and antibiotics sit among the most commonly-reported counterfeited drugs.
“Fake medicine distribution is rampant because business processes are siloed between the various industry stakeholders, which puts the industry at risk of fraud,” explains Heidi Patmore, a marketing consultant specializing in technology that’s changing consumer behavior.
“One solution to this would be cross-company process automation which could easily be enabled by a blockchain data interchange. This creates an open information system that all players can use to verify the authenticity of medication because it can track and trace it from when it’s manufactured to when it is dispensed to the patient.”
Companies such as IBM and SAP are working on blockchain solutions to weed out Africa’s counterfeit medication network. When medicine is returned to pharmaceutical manufacturers, for example, it is often re-sold instead of being destroyed. How can a small local pharmacy ensure what is returned is authentic? SAP are working with their existing client base – Merck, GSK, Ingelheim, McKesson and others – on a blockchain project to verify that any returned drugs are original.
IBM Research’s solution for Africa (currently in development in Haifa, Israel) includes a mobile interface and permissioned blockchain backend that enables each certified and authorized party in the network to initiate action, finish their transaction, and track its progress.
“It also includes the monitoring of temperature to ensure compliance with the proper conditions for transportation and asset transfer,” adds Inna Skarbovsky, a blockchain architect from IBM Research – Haifa. “Blockchain ensures full provenance for each medicine package, uniquely identified with a barcode or a serial number. This makes it possible for all authorized parties to track the drugs through the entire supply chain and the drugs’ life-cycle.”
This also allows significant cost reductions by eliminating each participant’s need to manage a separate system for traceability of its components. “It also improves procedural efficiency for change-of-hands, make it much harder for counterfeit drugs to be introduced into the supply chain and to be distributed to end-users,” says Skarbovsky.
Towett Ngetich is the CEO of Uthabiti Health, a Kenya-based pharmaceutical company that has implemented blockchain to bring transparency and accountability back to a country where statistics show that 30% of medicines sold are counterfeit. Uthabiti, which means ‘verify’ in Swahili, was started after Ngetich’s first-hand experience with the effects of fake health products: “Back in university, a significant number of students fell victim to unplanned pregnancies and unsafe abortions. With deep research, it was uncovered that there had been a supply of fake contraceptives and backstreet abortion pills into the student market,” explains Ngetich. More findings showed the presence of fake antibiotics, antiretrovirals (ARVs) and non-communicable diseases (NCD) medicines in the Kenyan pharmaceutical supply chain.
“Pharmaceutical science is the center of healthcare – one mistake in any drug composition or formulation has the risk of endangering a significant number of people. The need to access safe, affordable and quality health products in its simplest form means life and death in diagnosed health complications. Blockchain gives patients the ability to track and trace products using attached IDs – it also gives Uthabiti Health the ability to know where all our health products sit within each supply chain,” he says. Uthabiti Health procures medicines from different pharmaceutical manufacturers. Once received, they go to an internal laboratory for quality testing and are then labeled with the product’s safety lab report – attached in their codes is a unique blockchain ID. The medicines are then passed on to their partnering retail points, ensuring that the medicines dispensed to patients can be verified with something as simple as a text message.
“This brings in consumers in safe-proofing the supply chain of pharmaceuticals,” adds Ngetich.
The proliferation of fake drugs throughout Africa is complex – on average, medicine changes 30 hands before reaching the destined pharmacy – but blockchain technology has great potential to help stop counterfeit medicine distribution because it brings traceability and trackability to the entire pharmaceutical supply chain, ensuring the immutability of information.
While blockchain is still a relatively niche technology, it is slowly changing how organizations operate. Blockchain promises better security and transparency, but not necessarily for the customer, in the case of drug allocation: “Where blockchain technology could likely increase efficiency and simultaneously decrease the abuse of medicines, customers benefit. The pharmaceutical and related industries are unique however, in that the ‘consumer’ is also a patient – a vulnerable group with special needs and rights,” explains Candice De Carvalho, the founder of Easy Ethics CPD.
Although overall transparency in the supply chain increases through the use of blockchain, and this confers patient benefits, these must be weighed against patient privacy and confidentiality.
“With emerging technologies more freely available, we’ve observed an interesting shift in patient behavior, where data privacy is regarded less as an absolute by patients, in favor of a kind of sliding scale, where privacy itself is a currency that purchases medical benefits along the way,” adds De Carvalho. “Patients, for the right benefits, are perhaps more willing to part with some privacy privileges.”
De Carvalho questions the genuine knowledge that patients have of any exposure they experience through their use of novel medical device or systems innovations. The key drivers for the business are not necessarily unified with the total needs of the patient. However, the more the technology owners protect and balance the patient’s need for confidentiality and consent, the more they will ultimately see business benefit.
“In the context of a doctor-patient relationship, the doctor has a positive duty to enhance patient understanding so that the patient enjoys a truly informed consent. Does this then mean that technology providers are now responsible in the same way that medical health workers are?” she ends.
In Johannesburg, city-dwellers like Linah Moeketsi have taken the future of sustainable farming into their own hands. Where land is becoming scarce, they look to the skies.
Doornfontein is one of Johannesburg’s older inner-city suburbs with decaying buildings and dingy alleys that wear a dour, monochrome look.
Daily commuters and street surfers jostle with delivery vans and mountains of metal scrap but the grey of the concrete city makes it hard to believe that there could be a patch of green in a most unlikely location.
Above the humdrum of life here is a rooftop hydroponics farm looking down on the city, but upwards to a new route to restoration and urban preservation.
Atop the eight-floor Stanop building – offering a breath-taking view of the city and the landmark Ponte Towers in the distance – one woman has made it her mission to turn a grimy grey terrace into a green lung on the city’s skyline.
“City life is taking on a totally new direction… even people who think they couldn’t one day farm, find themselves on rooftops,” Linah Moeketsi tells FORBES AFRICA.
Moeketsi grows herbs, used to treat non-communicable diseases (NCDs), in a 250m x 500m greenhouse on the building’s terrace. But her rooftop farm is sans any soil – it uses a hydroponics system.
“I think because we are in the city and we would like to produce for people in the city, hydroponic farming is one of the answers because you can actually harvest more than twice the produce, and the growth rate is quicker and there is produce that you can have throughout the year that people demand because it is in a controlled environment,” she says.
On a windy Wednesday morning in October, we meet Moeketsi at her aerial green facility, a couple of days before she is to send some of her plant produce to the market.
She talks about her journey as an offbeat farmer. It all started when her father fell ill in 2013, when doctors failed to correctly diagnose his disease.
“They couldn’t see that he was diabetic. He didn’t show the signs of diabetes, but he had this foot ulcer that just wouldn’t go away,” she says.
“The future of city farming is great simply because we have more and more young people getting into this space. Even though it’s farming, they are looking at it from a very different angle.
Moeketsi decided to do her own research, so she read up books on African medicinal plants and used some herbs that belonged to her late mother, who had been a traditional healer.
“It took me a good eight months to help my dad and I actually saved him from having an amputation.”
The news of Moeketsi curing her dad’s diabetes using herbs spread. Sadly, her father died in 2016, at the age of 87. But she is proud to have helped prolong his life.
“So he passed away in his sleep, not sick, nothing, he was just old. But he was always grateful; he was like, ‘even when I die, I’m going to die with both my limbs’, so we would make a joke about it.”
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After her father’s demise, Moeketsi rented some land and turned her knowledge on natural herbs into a fully-fledged farm. However, when the owner of the land returned, she was forced to vacate.
Land was always going to be a problem in the city. But instead of giving up, Moeketsi looked to the skies.
“Because of this passionate drive for an answer, I found myself researching what’s happening outside Gauteng and South Africa, and I saw in Europe, they were farming on rooftops,” she says.
In 2017, her dream became a reality when she secured a deal with the City of Johannesburg as part of an urban farming program, and started the rooftop project a year later.
When we visit her greenhouse, we are welcomed by the sweet lingering scent of herbs. It’s hot and humid, and two fans whir away to cool the air.
Moeketsi walks around the greenhouse wearing dark glasses and a white jacket, with a syringe in hand – she could easily pass off as a medical doctor.
She elaborates on the hydroponics system. There are four pyramids, each attached to their own reservoirs of water. On each pyramid, different plants, ranging from spinach, lettuce, sage, parsley, basil and dill, rest on beds with pipes connecting them to the reservoirs. Moeketsi plucks out one of the pipes and inserts the syringe; water spouts out of the tube and she returns it to the bed.
“Twice a day, you have to check that water is actually going through the pipes, because that’s how the plants get water and nutrients,” she explains, as she unblocks a pipe using the syringe. She says it’s one of the best ways to farm using little water.
“When you put in certain plants in the greenhouse, you know you are guaranteed sustainable farming because you can produce those plants and harvest them,” she says.
Moeketsi adds that this allows her produce to stay consistent season after season.
“So, from that point of view, it makes the city more sustainable in terms of food produce that is easily accessible and cost-effective for the consumer because not everyone around here can afford the high prices of food but they can at least afford what we sell, whether it is at R10 ($0.5) or R15 ($1).”
As Moekesti continues to tend to the plants, a farmer she works with walks in and begins filling up the reservoirs.
Lethabo Madela has known Moekesti for almost six years.
“When you look around Johannesburg, there is no space, so rooftops have saved us a lot, especially those of us that love farming,” says Madela. “I’m learning a lot and I think she [Moekesti] changed the whole concept of farming for me because I used to farm vegetables. I didn’t know culinary herbs or medicinal herbs.”
Moeketsi speaks of other farmers around the city who have taken to the rooftops to farm plants such as strawberries, lemon balm, spinach and lettuce.
In a suburb called Marshalltown, a 10-minute drive from Moeketsi’s farm, Kagiso Seleka farms lemon balm also using hydroponics.
He produces sorbet and pesto from his produce which is then used to make ice cream.
“It [hydroponics] is great for farming sensitive plants in terms of temperature. Lemon balm does not like frost. But it’s better to grow even out of season so you can set a higher price,” he tells us.
However, he says hydroponics farming is a luxury not many farmers can afford.
“It [hydroponics] does have a bit of a higher capital upfront, but you get a higher yield and higher quality, so people are willing to pay more. Hydroponic planting saves about ninety five percent of water soil farming in a water-scarce country,” says Seleka.
“We do have water shortages, and I know people are on the whole ‘organic trip’ but, is it more important to have an organic plant versus a water-saving environment?”
The Program Coordinator for Agriculture at the City of Johannesburg’s Food Resilience Unit, Lindani Sandile Makhanya, says there certainly are more rooftop farmers in Johannesburg now than ever before.
Converting idle terraces into avenues of profit is becoming a norm. There are new rooftop farms being set up every day, offers Makhanya.
He regularly visits Moeketsi’s farm to check on the progress and collect produce to sell.
“Urban farming in Johannesburg is rising, mainly because the idea of producing our own food is very important because most people are moving to urban areas and therefore it stands to reason that we have to try to produce as much as possible,” says Makhanya.
“[There is growth] even in animal production, although we are moving away from the bigger numbers, but we are involving the smaller ones; because of the space issue, they are increasing overall.”
For Moeketsi, her farm has changed her life and given her hope for a better future. In addition to the teas, tinctures, ointments and medicinal products she processes from her plants, she plans to include more by-products such as syrups in the future.
“The future of city farming is great simply because we have more and more young people getting into this space. Even though it’s farming, they are looking at it from a very different angle,” she says. “That is why the city is changing and rooftop farming is going to get bigger and bigger.”
Clearly, farming in Africa is covering exciting new ground.
How Virtual Therapy Apps Are Trying To Disrupt The Mental Health Industry
Millions of Americans deal with mental illness each year, and more than half of them go untreated. As the mental health industry has grown in recent years, so has the number of tech startups offering virtual therapy, which range from online and app-based chatbots to video therapy sessions and messaging.
Still a nascent industry, with most startups in the early seed-stage funding round, these companies say they aim to increase access to qualified mental health care providers and reduce the social stigma that comes with seeking help.
While the efficacy of virtual therapy, compared with traditional in-person therapy, is still being hotly debated, its popularity is undeniable. Its most recognizable pioneers, BetterHelp and TalkSpace, have enrolled nearly 700,000 and more than 1 million users respectively. And investors are taking notice.
Funding for mental health tech startups has boomed in the past few years, jumping from roughly $100 million in 2014 to more than $500 million in 2018, according to Pitchbook. In May of this year, the subscription-based online therapy platform Talkspace raised an additional $50 million, bringing its total funding to just under $110 million since its 2012 inception.
The ubiquity of smartphones, coupled with the lessening of the stigma associated with mental health treatment have played a large role in the growing demand for virtual therapy. Of the various services offered on the Talkspace platform, “clients by far want asynchronous text messaging,” says Neil Leibowitz, the company’s chief medical officer.
Users seem to prefer back-and-forth messaging that isn’t restricted to a narrow window of time over face-to-face interactions. At BetterHelp, founder Alon Matas notes that older users are more likely to go for phone and video therapy sessions, whereas younger users favor text messaging.
“Each generation is getting progressively more mobile-native,” says John Prendergass, an associate director at Ben Franklin Technology Partners’ healthcare investment group, “so I think we’re going to see people become increasingly more accustomed, or predisposed, to a higher level of comfort in seeking care online.”
The ease and convenience of virtual therapy is another draw, particularly for busy people or those who live in rural areas with limited access to therapy and a range of care options.
Alison Darcy, founder and CEO of Woebot, a free automated chatbot that uses artificial intelligence to provide therapeutic services without the direct involvement of humans, says that with Woebot and other similar services, there is no need to schedule appointments weeks in advance and users can receive real-time coaching at the moment they need it, unlike traditional therapy. The sense of anonymity online can also lead to more openness and transparency and attracts people who normally wouldn’t seek therapy.
Along with stigma, the cost of therapy has historically acted as a barrier to accessing quality mental-health care. Health insurance is often unlikely to cover therapy sessions. In most cities, sessions run about $75 to $150 each, and can go as high as $200 or more in places like New York City. Web therapists don’t have to bear the expense of brick-and-mortar offices, filing paperwork or marketing their services, and these savings can be passed on to clients.
BetterHelp offers a $200-a-month membership that includes weekly live sessions with a therapist and unlimited messaging in between, while Talkspace’s cheapest monthly subscription at $260-a-month, offers unlimited text, video and audio messaging.
But virtual therapy, particularly text-based therapy, is not suitable for everyone. Nor is it likely to make traditional therapy obsolete. “Online therapy isn’t good for people who have severe mental and relational health issues, or any kind of psychosis, deep depression or violence,” says Christiana Awosan, a licensed marriage and family therapist.
At her New York and New Jersey offices, she works predominantly with black clients, a population that she says prefers face-to-face meetings. “This community is wary of mental health in general because of structural discrimination,” Awosan says. “They pay attention to nonverbal cues and so they need to first build trust in-person.”
Virtual therapy apps can still be beneficial for people with low-level anxiety, stress or insomnia, and they can also help users become aware of harmful behaviors and obtain a higher sense of well-being.
Sean Luo, a psychiatrist whose consultancy work focuses on machine learning techniques in mental health technology, says: “This why some of these companies are getting very high valuations. There are a lot of commercialization possibilities.” He adds that from a mental health treatment perspective, a virtual therapy app “isn’t going to solve your problems, because people who are truly ill will by definition require a lot more.”
Relying on digital therapy platforms might also provide a false sense of security for users who actually need more serious mental-health care, and many of these apps are ill-equipped to deal with emergencies like suicide, drug overdoses or the medical consequences of psychiatric illness. “The level of intervention simply isn’t strong enough,” says Luo, “and so these aspects still need to be evaluated by a trained professional.
– Ruth Umoh, Diversity and Inclusion Writer, Forbes Staff.
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