FUTURE HEALTH - SPECIAL REPORT - Julius Baer
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FUTURE HEALTH SPECIAL REPORT
1
FOREWORD
By Dr Damien Ng The healthcare system as we know it today can trace its eating and sleeping habits) and also more efficient ways
Next Generation Research Analyst origins to the beginning of the 20th century. Based predo- to manage all aspects of our health, such as the remote
minantly on a sick-care model, the system is essentially one monitoring of blood pre ssure and the adhe re nce to
that waits until we have fallen ill before it kicks into action. medication.
In other words, acute care sits at the centre of the conven-
tional approach, at the e xpe nse of pre ve ntion and e arly Another change will come in the form of genomics. There
intervention. The way medical care is delivered to patients are still many diseases in the world today that do not have
has change d surprisingly little , de spite the tre me ndous cures. Medical professionals and scientists are increasingly
progress that has been achieved. The majority of ill people turning to genomics, artificial intelligence, and big data to
continue to be seen and treated by medical professionals better predict individuals’ risk of contracting certain types
in brick-and-mortar clinics and hospitals. of dise ase s, with the ultimate aim of de riving preve ntive
measures and tailor-made treatments depending on their
However, healthcare costs have been rapidly rising over the unique genetic make-up. In the meantime, genomics will
past few decades. This unsustainable increase can be largely also change the way we treat many of these illnesses when
attributed to the growth of the human tide in the form of they do develop.
population ageing and a resulting higher incidence of chron-
ic diseases. Together with the advance of rapidly evolving With so many new developments in the field and a sharp-
digital technologies and shifting consumer preferences for e ne d focus on the we akne sse s of our curre nt he althcare
convenience and affordability, demand for a more efficient systems following the outbreak of Covid-19, it is clear that
delivery model is growing ever louder. One of the major the healthcare system of the future needs to look very dif-
trends presently under way is the transition away from a ferent from today’s approach. The purpose of this report is
volume-based care model to a value-based one, in which to explore the ways in which healthcare might change in
patients are more likely to receive the best available care the coming decades. We start by looking at the situation
from the ir provide rs without ove rpaying. Having an in- today be fore pre se nting pote ntial route s forward, ne w
depth understanding of the patient through the collection te chnological and me dical developments, societal shifts,
and exchange of data is key for this transition. and the views of industry experts.
The focus of healthcare will gradually shift to a more in- Healthcaresystems havebeen slow to change, resisting the
dividual approach. Instead of focusing on sickness, the disruption that has swept through so many other industries.
emphasis will be on the personal experiences and overall But now could be the time to accelerate an evolution – if
well-being of the consumer. This could come in the form not a revolution – in the way we think about looking after
of invaluable support for our lifestyle patterns (including ourselves. So, are you ready for the future of health?
CONTENTS
4 FUTURE HEALTH
How to improve modern healthcare
10 GOING VIRAL
The digital world is reinventing medical treatment
14 TECH’S HEALTHY FUTURE
Artificial intelligence is emerging as a major force in health
18 INNOVATION IN THE TIME OF CORONA
A range of industries have adapted to produce medical equipment
20 HOME DISPENSARY
A series of portraits by photographer Gabriele Galimberti
34 WHO WANTS TO LIVE FOR EVER?
A rise in life expectancy is kick-starting the longevity business
40 A HEALTHCARE REVOLUTION
The life sciences are coming to the fore in a variety of disciplines
46 BINARY CHOICES
The challenge of blending the data revolution with medical practice
50 BETTER RELATIONSHIPS, BETTER HEALTH
Why companionship is crucial to a healthy life
56 IMPORTANT LEGAL INFORMATION
58 MASTHEAD
FUTURE
5
HEALTH
By Dr Damien Ng and Emily Rookwood
The Covid-19 pandemic has exposed a number of problems
in our healthcare systems that have been bubbling under the surface
for years. The good news is that the crisis will help to supercharge the
technological progress the industry needs.
6 FUTURE HEALTH
“We are experiencing a
perfect storm of outdated,
under-resourced
infrastructure, and
increased demand that has
left the failings in our
global healthcare systems
exposed.”
Our healthcare systems have never been in sharper focus
than today. Face d with a pande mic on a scale not se e n
since 1918, me dical infrastructure is be ing pushe d to
breaking point – and its dedicated staff with it. The signs
that our systems are not working as well as they could have
been there for decades, but the Covid-19 crisis means it is
no longer possible to ignore them.
We are experiencing a perfect storm of outdated, under-
resourced infrastructure, and increased demand that has
left the failings in our global healthcare systems exposed.
This is de spite global spe nding on he althcare incre asing
at a considerable rate since 1980 because of government
policies and lifestyle changes.
There are several reasons why these costs are on the rise.
First, life expectancies are increasing all over the world. For
the first time in human history, by 2030 the numbe r of
people aged 60 and above will surpass those under the age
of 10. This global demographic change is putting health-
care systems everywhere under extreme stress as they try
to cater to the needs of ageing populations; in the United
States, for example, people over 60 account for nearly half
the total healthcare costs, despite making up just 22 per
cent of patients.
Second, our modern lifestyles have brought about an in-
crease in chronic, non-communicable or ‘lifestyle’ diseases
driven by behaviours such as poor diet, smoking, lack of
exercise, and overconsumption of drugs and alcohol. These
conditions, once conside re d dise ase s of high-income
countries, havespread rapidly around theworld, correlating
strongly with incre asing urbanisation and e conomic de -
velopment. They have replaced infectious diseases as the
le ading global cause s of de ath, and the World He alth
Organization (WHO) estimates that by 2030 total global
de aths from non-communicable dise ase s will re ach 52
million a year, exerting extreme pressure on already over-
worked healthcare systems.
Third, de clining fe rtility rate s have le d to a shortage of
workforce caused by demographic squeeze. This pheno-
me non has the e ffe ct of alte ring the sustainability of
FUTURE HEALTH 7
8 FUTURE HEALTH
“Healthcare has improved vastly in the past 50 years,
but expectations of what should be provided
as standard have increased at a far higher rate.”
he althcare syste ms due to the unbalance d supply and Economist Intelligence Unit reported that this model is
demand of resources in high and middle-income coun- still in the early stages but countries such as Sweden are
tries. The labour situation is further exacerbated by the starting to align the ir he althcare with a more out-
wave s of baby-boome r he althcare worke rs who are come-based system.
beginning to retire, intensifying global competition for
skille d he alth worke rs. According to the WHO the re The Organisation for Economic Co-operation and De-
will be a worldwide shortfall of around 18 million health ve lopme nt (OECD) and Europe an Commission both
workers by 2030, with deficits already striking particu- produced reports on VBHC in 2019, and consulting groups
larly hard in low to middle-income economies. and medical companies such as Boston Consulting Group
(BCG) and Medtronic are highlighting the effectiveness
Lastly, our expectations have changed. Healthcare has of this new model. One case study by BCG highlighted
improved vastly in the past 50 years, but expectations reductions of up to 30 per cent in unnecessary inpatient
of what should be provided as standard have increased stays and up to 74 per cent in the rate of re-operation
at a far higher rate. As our incomes have increased, we afte r complications in bre ast cance r patie nts afte r the
have come to expect an ever-higher level of healthcare hospital group Santeon introduced a VBHC approach.
– which obviously comes at a cost.
Anothe r mode l that could significantly improve avail-
What can be done to improve the situation? Luckily, ability and efficiency of global healthcare systems, and
the re are many opportunitie s and positive de ve lop- is currently proving valuablein thebattleagainst corona-
ments on the horizon. One of the first areas to consider virus, is telemedicine. Switzerland began exploring the
is the model our healthcare systems run on. In the ma- potential of telemedicine in 2003, and today many he-
jority of countries, healthcare is based on the traditional alth insurers provide telemedicine services as standard.
fee-for-service reimbursement model, where the incen-
tives are skewed towards performing procedures rather Tests have also begun of video medicine and smart self-
than making correct diagnoses. However, governments measurement devices that patients can use in their own
and insurers are increasingly shifting towards an outco- home s. In China, te le me dicine has be e n promote d
me -base d mode l, such as the value -base d he alth care by the gove rnme nt since 2014, and Ping An’s Good
(VBHC) model which is based on the research of Har- Doctor application is now the world’s le ading online
vard Professor Michael Porter. This model compensates healthcare platform. As well as offering telemedicine, it
he althcare provide rs for the he alth and we ll-be ing of works with pharmacie s and hospitals as a hub for
their patients, rather than for the services they provide. medical services. Although Europe has been slow to ad-
In a recent study on the adoption of VBHC globally, the opt such se rvice s be cause of patie nt and re gulatory
reticence, the use of telemedicine is increasing: in 2018
the Europe an Commission e stimate d that the global
market would grow to EUR 37 billion by 2021, and the
current crisis is likely to accelerate that growth.
Which brings us to the broader topic of technology. New
de ve lopme nts could hold the ke y to many he althcare
improvements and offer a number of exciting opportuni-
ties for patients and investors, with digital data helping
to build robust syste ms that de live r value -base d care .
While you might assume that developed countries such
as the US, Germany, or the UK might be leading the way,
in fact China, India, and Russia are adopting the most
revolutionary approach when it comes to incorporating
te chnology into me dicine . The 2019 Philips FutureFUTURE HEALTH 9
Health Index revealed that 94 per cent of Chinese, 88
per cent of Indian, and 81 per cent of Russian healthcare
“Switzerland began
professionals use some form of digital health technolo-
gies or mobile health apps, compared with a global aver-
age of 78 per cent. This is compared to 75 per cent in
Brazil, 64 per cent in Germany and only 48 per cent in exploring the potential of
South Africa (see chart below). Following the Covid-19
crisis, the already booming medtech sector has ramped
telemedicine in 2003, and
up its developments at a phenomenal pace (read more today many health insurers
provide telemedicine
about telemedicine and the medtech boom on page 10).
These technological developments are not the only po-
sitives to look forward to when it comes to future health. services as standard.”
Longevity science is becoming a multibillion-dollar in-
dustry (se e more on page 34) and the bre akthroughs
coming out of this sector mean that we can live not only
longer, but healthier, fuller lives. A boom in life sciences On a more pe rsonal note , ne w re se arch showing how
driven by global hubs such as Geneva’s Campus Biotech, good re lationships can boost our he alth is he lping to
the European Medicines Agency in Amsterdam, and the drive a social health revolution. One recent report from
Life Sciences Institute in Singapore are exploring myriad Harvard Medical School says: “Social connections…not
ways to improve our health, from AI support for stroke only give us pleasure, they also influence our long-term
patients to unlocking new developments in genomics. health in ways every bit as powerful as adequate sleep, a
good diet, and not smoking.” Governments, non-profit
organisations, and communities are coming together to
boost inte rge ne rational e xchange s, from nurse rie s in
USE OF HEALTHCARE TECHNOLOGIES re tire me nt home s to me ntoring sche me s for young
BY HEALTHCARE PROFESSIONALS, 2019 e ntre pre ne urs run by re tire d CEOs. Efforts to re build
the sense of community that had all but disappeared in
many areas have doubled since the enforced isolation of
CHINA the recent pandemic, and have highlighted the medical
94 % concerns associate d with loneliness. As we look to the
future of health and healthcare it is clear to see that we,
INDIA the community, have a very large and important role to
88 % play as we take more responsibility for our wellbeing.
RUSSIA Last, but not le ast, we turn to the me dical profe ssion.
81 % The one une quivocal stre ngth of he althcare syste ms
around the world is their staff. The coronavirus outbreak
GLOBAL AVERAGE has pushed the profession to its very limits, but day after
78 % day, doctors, nurses, porters, and all manner of medical
workers are risking their lives to help others. While there
BRAZIL are many areas of our systems that need to improve in
75 % ye ars to come , one thing that we hope re mains a ke y
feature is a dedicated workforce who really put the care
GERMANY in healthcare.
64 %
SOUTH AFRICA NEXT GENERATION RESEARCH
48 %
We are currently experiencing a significant shift in global
lifestyles. Around the world people are living longer and
lobal average of healthcare professionals currently using some
G the proportion of elderly citizens is increasing year on year.
form of digital health technologies or mobile health apps This is having a significant effect on our healthcare sys-
te ms and how we manage our he alth on a daily basis.
ountry-specific healthcare professionals currently using some
C Digital he alth, longe vity, ge nomics, and global he alth
form of digital health technologies or mobile health apps aware ne ss are all ke y compone nts of the ‘Shifting Life -
style s’ me gatre nd, one of five me gatre nds curre ntly
cove re d by Julius Bae r’s Ne xt Ge ne ration Inve stme nt
approach, which identifies the structural trends that will
shape the world in the coming years.GOING
11
The Covid-19 pandemic has fast-forwarded the spread of health tech.
Once distinctly different areas – telemedicine, wearables, smartphone
apps, and the Internet of Things – are converging to revolutionise
the way we think about healthcare.
By John Arlidge
VIRAL12 FUTURE HEALTH
markably slow to e xploit ne w te chnology. Although
some countrie s have we ll-e stablishe d te le me dicine
se rvice s – notably Switze rland and China, whe re Ping
“The Covid-19 crisis An’s Good Doctor offers more than 300 million users
is acting as a access to remote consultations as well as a number of
other medical services including appointments, referrals,
catalyst for the whole and prescription delivery – the majority still rely almost
e xclusive ly on the me dical practice approach. That’s
digital healthcare large ly down to re gulation and conce rns for patie nt
privacy (see panel). The Covid-19 pandemic has forced
and telemedicine governments around the world to rethink radically their
industry.” approach to telemedicine. It is no longer a ‘nice to have’,
but a ‘need to have’.
Med-tech firms can scarcely believe their good fortune.
“The Covid-19 crisis is acting as a catalyst for the whole
digital healthcare and telemedicine industry,” says Luke
Big shocks change things dramatically overnight. Take Buhl-Nie lse n, vice pre side nt of busine ss de ve lopme nt
9/11. It transformed security, government surveillance, and operations at Kry, a leading telemedicine operator
and air travel in a heartbeat. The Covid-19 pandemic is base d in Swe de n. “Le gislation is moving at bre akne ck
doing the same in health. It has prompted the most rapid spe e d,” adds Joost Brugge man, co-founde r and chie f
and radical innovation in long-distance , te ch-base d e xe cutive of Siilo, a Dutch communications tool for
public he althcare the world has e ve r se e n. What te ch medical professionals. “It usually takes 12-18 months to
e vange lists have spe nt ye ars lobbying for has be e n convince middle management to approve innovations.
approve d almost ove rnight, cre ating unpre ce de nte d Right now they’re saying, ‘Give it to us, we’ll figure out
growth and investment opportunities. the contracts later.’”
Following the outbreak in the UK, the notoriously slow Teleme dicine isn’t simply about real-time interactions.
National He alth Se rvice (NHS) chose 11 supplie rs to It also includes mHealth, which covers the use of emer-
provide video consultations in just 48 hours. More than ging te chnologies to create a new virtual health space
7,000 doctors’ offices were ordered to conduct as many for both patients and telemedicine providers. mHealth
video and phone consultations as possible. The propor- taps into the Internet of Things, such as environmental
tion of NHS healthcare delivered through video calls or sensors, wearable devices, and mobile apps, for tracking
text messages increased from a meagre 1 per cent to 5 and measuring patients’ health and well-being conditions.
pe r ce nt in a matte r of days, according to the Digital
Health Council, a trade body. Previously, online consul- This is where the tech giants are trying to get in on the
tations were practically non-existent. game. Apple has launched Health Kit, which integrates
Ove r in the US, he alth-privacy le gislation has be e n
amended to allow companies such as Apple, Google, and
“Over in the US,
Microsoft to facilitate virtual doctors’ visits through
FaceTime and Skype . Microsoft also plans to launch a
new booking tool for hospitals and doctors, who already
use its Te ams collaboration software to vide o-call pa-
health-privacy legislation
tients. Hospitals everywhere are testing out Microsoft’s
HoloLens technology to reduce the number of doctors
has been amended
exposed to patients with Covid-19. A doctor wearing the to allow companies
such as Apple, Google,
augme nte d-re ality goggle s can broadcast image s and
audio from a patie nt e xamination back to colle ague s
outside the room using the Teams app. This minimises
the numbe r of he althcare worke rs who are e xpose d,
and Microsoft to
re duce s the amount of prote ctive e quipme nt ne e de d,
and helps patients get better access to specialists, who
facilitate virtual doctors’
can dial in remotely. visits through
The te le me dicine re volution has not come a mome nt FaceTime and Skype.”
too soon. For an industry of its size – global healthcare
is worth an estimated USD 11.9 trillion – it has been re-GOING VIRAL 13
data from wearable devices, including the Apple Watch,
MOBILE (PHONE) HEALTH to enable care teams to spot – or even predict – illness.
The latest Apple watches have ECG sensors that can alert
Since the coronavirus first began to spread, if it’s designed with the best intentions,” says users if they have potentially dangerous irregular heart
smartphones havebecomevital tools in track- Matt Blaze, a professor at Georgetown Law rhythms. The Cupertino giant is also rolling out its He-
ing the spread of the disease. Some develop- who specialises in computer science and pri-
me nts are aime d at he lping individuals to vacy. “It’s not to say you should never collect alth Records feature, which is designed to make it easier
ide ntify first symptoms of the illne ss. The or use data – only that you should be ve ry to store and use medical data on iPhones. “If you zoom
fe rtility tracke r app Natural Cycle s, for e x- humble about what assurance s you offe r out into the future, and look back and ask the question
ample, has added in new vital signs monito- about privacy.”
ring options. More ge ne ral apps have be e n ‘What was Apple’s greatest contribution to mankind?’,
updated to monitor and analyse user behavi- The pote ntial and the pitfalls are ve ry we ll It will be about health,” says the firm’s CEO, Tim Cook.
our in an attempt to slow the spread of the illustrated by the controversy around efforts
virus. The se range from apps like We Chat by Apple and Google to cre ate a Covid-19
and Alipay that now share pe rsonal data track-and-trace app to he lp to e nsure that In Seattle, Amazon is working on something inevitably
with the Chinese government, to the use of the re is no se cond spike in infe ctions. The dubbed Amazon Prime health, which will have more of
anonymised mobile data to monitor popula- upside is cle ar. He re are two usually bitte r a supporting role for healthcare providers. It starts with
tion movements during containment. Silicon Valle y rivals coope rating with e ach
other for the common good. Alexa, the firm’s voice-controlled virtual assistant. ‘She’
In the short term, these measures are proving has begun using US government information to answer
invaluable in the fight to contain the pan- However, privacy activists and many of the health queries. Ask her what your symptoms mean and
demic. But there’s a big ‘but’, which Dr Tehilla firms’ customers say that plans to share with
Shwartz Altshuler, head of the democracy in gove rnme nts the location and he alth data she ’ll te ll you. She can e ve n call 911 in an e me rge ncy.
the information age programme at the Israel the app generates are an unacceptable inva- Face book is trying to do some thing similar, cre ating a
Democracy Institute, puts well. “We can use sion of privacy. Apple and Google have come tool called Preventive Health to encourage users to at-
any technology to fight this horrible disease. down on the side of privacy, which means the
The question is, who will supervise it and who app will not be much he lp in combating a te nd che ck-ups. Use rs can book appointme nts on the
will promise that after this is over, we won’t future outbreak. Facebook platform and opt to receive personalised pre-
become a surveillance democracy?”
ventive healthcare recommendations and check-up re-
Health authorities in some US states, as well
Privacy advocate s worry that the curre nt as in countries such as Canada and Britain, minders, including routine health exams, mammograms,
measures already represent too great an in- urged the two firms to give them more con- flu shots, and blood pressure screenings.
trusion into our private lives. Hong Kong uses trol over the kinds of information their apps
phone apps and smart brace le ts that show can collect. So far, that has not been forth-
where citizens and visitors are. Spreadsheets coming. Some governments have reacted by What other trends are emerging? Remote health moni-
and lists ide ntifying pe ople living in or trying to create their own apps but the prob- toring technology for hospitals looks set to boom. Many
re turning home from Wuhan, the Chine se lem is, they don’t work very well on Google hospitals, notably in the US, are already using it to treat
city whe re the virus first took hold, have and Apple handsets because they have not
be e n circulating on social me dia in China. be e n de signe d by Google or Apple . And Covid-19 patie nts with milde r symptoms in the ir
Singapore ’s he alth ministry has poste d round and round the debate goes. homes. Most are giving patients wearable devices that
information online about e ach coronavirus
are worn 24/7 to track vital signs. Artificial intelligence
patient, often in great detail. The key question is: what’s more important
in an emergency – privacy or the state? It’s establishes a baseline reading for each patient and data
Such pe rsonal information can have major not an acade mic que stion any more . It’s a from the wearable is transmitted to the hospital, where
implications for an individual’s safe ty and matter of life and death. doctors can quickly spot anomalies, such as a decrease
economic and social well-being.
“We need to have a discussion on how Silicon in oxygen levels.
“One of the things we have learned over time Valley is increasingly taking over the job of a
is that some thing that se e ms anonymous, nation state,” said one German official. “But New tech – and the global race to develop a Covid-19
more often than not, is not anonymous, even we don’t need to have it amid a pandemic.”
vaccine – will also accelerate clinical trials, a market that
is worth USD 65 billion according to CB Insights. The
trial process can take an average of 7.5 years and cost up
to USD 2 billion per drug, according to the research firm.
“If you’re a physician working on a clinical trial, your ex-
pe rie nce is probably no diffe re nt than 20 or 30 ye ars
ago,” says Gary Hughe s, chie f e xe cutive of Te ckro, a
software platform that tries to make the process of par-
ticipating in trials e asie r for doctors and patie nts. “It’s
still a people and paper process.” Ireland-based Teckro
has raised USD 25 million from investors, including Peter
Thiel’s Founders Fund. US biotech firm Amgen is using
artificial intelligence to improve trial planning so that it
does not waste time and money setting them up in pla-
ces where there will be few participants.
One thing is certain. As telemedicine spreads, we will all
spend less time in germ-filled waiting rooms. And even
themost confirmed Ludditewould agreethat is progress.TECH’S
15
HEALTHY
FUTURE
By Rhymer Rigby
Artificial intelligence was already becoming a key part of
healthcare in the 21st century even before the Covid-19
pandemic made technological advances more urgent.16 FUTURE HEALTH
The coronavirus pandemic means that healthcare is at Martin Ciupa is an expert in AI. He is CEO of the start-
the top of everyone’s minds. Governments, healthcare up Me ntal Image ry, CTO of Kimbocare , a blockchain-
providers, and businesses are focusing as never before enabled tech platform, and has served as chief AI officer
on doing more, faster, and better. This often means using at Mindmaze, a Swiss unicorn that builds intuitive human
new technologies, one of which is artificial intelligence. machine interfaces. Recently, he was also elected leader
of the Ame rican Association of Pre cision Me dicine ’s
When we think of artificial intelligence, we tend to think Data Science Coronavirus Taskforce. He believes there
of highly inte llige nt robots or compute rs that would are four main areas where AI will improve medicine: pro-
pass theTuring test – that is, you cannot distinguish them ductivity, quality, personalisation, and discovery.
from a human. This is sometimes called ‘Strong AI’ and
is de cade s from be coming a re ality. The good ne ws is The first, productivity, is about making healthcare more
that lesser forms of AI such as machine learning and deep e fficie nt. “AI can re lie ve pre ssure s on he althcare and
learning are here now and being used in healthcare. also augment people, allowing them to do more work in
a given day,” says Ciupa. This is a potentially huge de-
In fact, AI re cognise d the coronavirus e pide mic ve ry velopment. To take the first statement, according to the
early on. The AI platform BlueDot spotted and flagged ‘Harvard Business Review’, labour is the single biggest
a cluster of ‘unusual pneumonia’ cases on 30 December cost in US healthcare. Moreover, productivity has been
last ye ar, ne arly a we e k be fore any official announce - de clining for de cade s and it is e stimate d that of the
ments weremade. BlueDot takes its data from thousands USD 3 trillion spent annually on healthcare in the US, a
of sources, ranging from airline ticketing to public health third is wasted.
announce me nts. Inde e d, this is one place whe re AI
come s to the fore – the ability to take unimaginable This wastage is often most visible in areas such as poor
amounts of data in different formats. be d allocation and othe r administrative ine fficie ncie s.
But it also manife sts itse lf in having e xpe nsive pe ople
such as doctors doing administrative or mundane medi-
cal tasks, the kind of things AI excels at. Use it to replace
“Martin Ciupa believes people and not only do you save money, but also doctors
can spend more time with patients.
there are four main areas
When it comes to productivity, it is worth remembering
where AI will improve that healthcare is very different from other industries. In
medicine: productivity, he althcare syste ms across the world, de mand consis-
te ntly outstrips supply (or affordable supply). Thus, if
quality, personalisation, you can provide more service for the same expenditure
you are likely to have a healthier population, not greater
and discovery.” numbers of unemployed doctors or nurses. People will
‘consume’ more healthcare and the world will be a better,
fitter place for it.
In the US, a project involving organisations such as Micro- The second area is quality. “An example of this is examin-
soft Research, the National Library of Medicine, and the ing X-rays and MRI scans,” says Ciupa. “Deep learning
Allen Institute for AI is under way to mine useful infor- is really good at looking at medical images and already
mation and gain insights from around 30,000 research performs at similar radiological levels to human experts.”
papers on the novel coronavirus and its wider family.
In late 2018, Stanford University announced it had de-
Othe r AI applications are also be ing mobilise d in the veloped a new algorithm that could read chest X-rays as
fight against the virus. Examples include facial recogni- well as radiologists. Crucially, this algorithm was reading
tion syste ms that can de te ct the symptoms of fe ve r, them for 14 different pathologies, not just one, represen-
sophisticate d monitoring e quipme nt, AI chatbots for ting huge potential efficiency gains. Te chnology could
online consultations, and software for pandemic model- e ve n le ad to digital consultations; me d-te ch company
ling. Israe li company Nanox has de ve lope d an e asily Babylon has claime d its chatbots can alre ady surpass
portable digital X-ray syste m that conne cts to cloud- doctors in terms of the accuracy of diagnosis.
based AI to diagnose infections and help prevent future
outbreaks. The benefits of automating routine tasks such as initial
consultations range from vastly reduced waiting times in
But what about healthcare more generally? What possi- the developed world to access to medical services for the
bilitie s doe s AI hold for a he althie r world once we ge t first time in the developing world. Huge strides are al-
through the current crisis? ready being made with telemedicine in Africa.TECH’S HEALTHY FUTURE 17
“AI can relieve pressures on healthcare
and also augment people, allowing them
to do more work in a given day.”
The use of AI to dige st huge amounts of data could treating it.” Nor is it just the obvious stuff. AI might mean
result in other discoveries too. “There’s a trial at London’s tailore d, virtual re ality physiothe rapy, for e xample .
Moorfields Eye Hospital where AI is being used to look Again, this would be likely to deliver better, faster, and
at thousands of e ye scans,” says Kim Nilsson, CEO of cheaper results.
Pivigo, a data sciencemarketplaceand training company.
The scans are compare d and cross-re fe re nce d with an The last and pe rhaps most e xciting are a whe re AI will
individual’s medical history to see if they can show that be a game -change r is the discove ry of ne w drugs.
patie nts are at risk of othe r conditions. “For instance , “De ve loping a ne w drug can cost USD 1 billion,” says
does your scan indicate you are at risk of diabetes?” Nilsson. “AI could cut that in half.” It can do this in all
sorts of ways. The obvious ones, perhaps, are sequencing
Nilsson adds that the use of AI to analyse and interpret the DNA or RNA of new viruse s and mapping the m to
huge amounts of data will become ever more important suggest which treatments are likely to be most effective.
as the Inte rne t of Things take s off and smart de vice s Others include screening and monitoring participants in
proliferate. With wearables that constantly stream infor- medical trials.
mation on your health, people could be monitored in real
time and AI could pick up problems such as heart con- One of the most promising possibilities is re purposing
ditions while they are minor and easily treatable – and existing drugs to treat new conditions. AI’s ability to find
even before any conditions develop. needles in haystacks of data is key here. Existing drugs
do not ne e d the same sort of clinical trials; the ir side
While AI can discern patterns in the data of millions of effects areknown, they arealready FDA or EMA-approv-
patie nts, it can also make tre atme nt on an individual ed, and they are cheaper and more efficient. “You might
basis much more personal. This will result in better out- look at an existing drug for arthritis that also has possi-
comes and lower costs because people receive treatment bilities for treating high blood pressure,” says Nilsson.
tailore d spe cifically to the m. In a re ce nt note , Giulia
Besana, an analyst at IDC Health Insights, wrote: “Euro- Ultimately, the future that AI and associated technolo-
pean healthcare providers are betting on AI to support gie s hold for me dicine is one of vastly more data and
greater personalisation of healthcare services.” vastly more use ful knowle dge gle ane d from that data.
“You will go about your daily business while wearing your
What does this mean in practice? “If you think of current watch and your smartphone,” says Ciupa. “Thedata from
healthcare as Healthcare 3.0, it’s set up a bit like one of these devices will allow AI to detect problems and rec-
Henry Ford’s factories,” says Ciupa. “You come into hos- omme nd pe rsonalise d tre atme nts be fore you know
pital and get on a production line. You are given a stan- anything is wrong.”
dard battery of tests until the hospital discovers what is
wrong with you. However, AI will result in Healthcare 4.0. You will suffer from fewer illnesses and you will recover
This, like Industry 4.0 more generally, will mean greater quicke r. Inde e d, some , such as Babylon’s Dr Ali Parsa,
automation, cyberphysical systems, data exchange and have predicted that AI and associated technologies will
proliferation of AI.” be so revolutionary for healthcare that in a decade or so
the issue of funding will no longer be a problem.
For patients this will deliver a far more tailored, person-
alised service from the word go. The business of health- But all this is some way in the future . Right now, all
care will become more efficient, and far more factors will e ne rgie s are focuse d on the coronavirus. And he re , AI
betaken into account during consultation and treatment. doe s have an important role to play. It won’t stop this
“For e xample , a pe rson who has Alzhe ime r’s may also pandemic but, by crunching vast amounts of data, it may
have depression and anxiety,” says Ciupa. “At the mo- spe e d up the race to find a vaccine and he lp pre dict
me nt the se ofte n cannot be take n into account whe n future outbreaks.INNOVATION
18 FUTURE HEALTH
IN THE TIME
OF CORONA
COMPANY Nike, US COMPANY Sharp, Japan COMPANY Beiersdorf, Germany
PRINCIPAL OUTPUT Sporting goods PRINCIPAL OUTPUT Electronics manufacturer PRINCIPAL OUTPUT Skincare product manufacture
and clothing manufacturer PIVOT Pivoted a TV plant manufacturing PIVOT Simultaneously producing medical
PIVOT Repurposing existing elements used to LCD display panels to produce face masks disinfectants alongside skincare products from
produce Nike trainers to make face shields for Japanese population brands including Nivea and La Prairie
PRODUCTION Distributed across Oregon, PRODUCTION From 150,000-500,000 PRODUCTION 500 tonnes to be distributed
Massachusetts, Tennessee, Missouri, a day as production ramps up across Europe from production sites in
Ohio, as well as Belgium, Netherlands, China Germany and Spain
FACE SHIELD FACE MASK SANITISER19
Need is one of the most powerful drivers when it comes to innovation. The urgent need
for medical equipment and supplies caused by the Covid-19 pandemic has led to
an unprecedented response not only from the medical sector, but also from myriad
other industries. From hospitality and motoring to cosmetics and luxury fashion,
businesses have come together to bridge the gap between supply and demand in
a remarkable show of global solidarity. While hotels and restaurants have been
supplying accommodation and meals for medical staff, industries with manufacturing
capabilities have transformed their production lines to make medical equipment,
such as ventilators and CPAP (continuous positive airway pressure) machines, and
PPE (personal protective equipment), including face shields, masks, and gloves.
Here we illustrate some of the innovative pivots that companies around the world
have made in their drive to contribute towards the relief efforts.
COMPANY Prada, Italy COMPANY LVMH, France COMPANY JCB, UK
PRINCIPAL OUTPUT Luxury PRINCIPAL OUTPUT Luxury goods conglomerate PRINCIPAL OUTPUT Manufacturing equipment
fashion manufacturer PIVOT Perfume production lines of Dior and Guerlain including earth excavators and diggers
PIVOT Diverted production to switched to producing hand sanitiser in PIVOT Producing steel casing for emergency
medical overalls and masks for 72 hours; jeweller Bvlgari turned its factory in CoVent ventilators designed with Dyson
hospitals across Tuscany Lodi (Italy) from producing perfumes and hotel PRODUCTION 10,000 initial order from UK
PRODUCTION 80,000 medical amenities to hand sanitiser gels government, now no longer required due
overalls, 110,000 masks produced PRODUCTION 12 tonnes of sanitiser to 39 hospitals to specification changes
at the factory in Perugia in France, plus expansive global response; hundreds
of thousands of sanitiser gel bottles distributed
in Italy and the UK
MEDICAL OVERALLS SANITISER COVENT VENTILATORHOME
21
DISPENSARY
By 2023, it is estimated that the global pharmaceutical market will
exceed USD 1.5 trillion, with key growth coming from ‘pharmerging’
markets. But medicines are not just mere commodities: they offer an
insight into differing behaviours and cultures around the world.
Photos by Gabriele Galimberti
By 2023, it is estimated that the global pharmaceutical market will exceed style trends among the global population. As a much broader approach
USD 1.5 trillion, with key growth coming from ‘pharmerging’ markets in- to health – one that encompasses our diet, fitness, lifestyle, and overall
cluding the BRIC countries, Mexico, Turkey, Thailand, and South Africa. wellness – is increasingly adopte d, the use of immune boosting supple -
The highe r-income countrie s, howe ve r, maintain the highe st pe r capita ments as well as integrated traditional and complementary medicine is on
consumption of pharmaceuticals, and as new treatments become available the rise.
this continues to rise: global medicine use has increased by 3 per cent a year
since 2014, and by 2019 global defined daily doses stood at 1.822 billion. Photographer Gabriele Galimberti’s ‘Home Pharma’ series offers intimate
portraits of the personal and cultural differences in medicine consumption
Me dicine s are not just commoditie s; the y offe r an insight into diffe ring across the globe, while reinforcing the fact that whatever your approach to
behaviours and cultures around the world and speak to wellness and life- health and lifestyle, medicines are a part of everyone’s daily life.22 FUTURE HEALTH
Arnaud Brunel and his wife Candelita in their house in Lausanne, Switzerland. Arnaud is CEO of Tectona.
He is also an avid collector of photography and supporter of various photographic institutions. In the photograph,
some of the works he owns are visible, including by Richard Avedon, Andres Serrano, and Vik Muniz.HOME DISPENSARY 23
Marco Segato, 47, Vittoria Ruzzi, 30, Gherardo, 4, and Pietro, 1, are Italians but live in a high-end condo in Miami, USA. Marco is an agent
for luxury yachts built in Italy, while Vittoria is an architect. They travel, often to exotic destinations, both for pleasure and work.
Many of the medicines in their house come from Italy where, in contrast to the USA, there is a single-payer healthcare system.24 FUTURE HEALTH
Susan Fisher, 35, is a yoga teacher and has a popular yoga studio just under her apartment in a trendy area of Zurich, Switzerland. She does not
use allopathic medicines, only homeopathic remedies. She also uses Ayahuasca wine, which can be seen in the red jar at the centre of the photo.
Ayahuasca is a traditional brew of leaves and roots consumed as a spiritual medicine in ceremonies among the indigenous peoples of the Amazon basin.
Its effects include hallucinations, spiritual revelations, and vomiting, considered to be an essential part of the experience as it represents the release
of negative energy and emotions. It has become increasingly popular among Westerners.HOME DISPENSARY 25
Henri Caillet, 92, getting some exercise in his home in Bretigny, Switzerland. Henri was a manager in a factory in the German part
of Switzerland and a very keen player of pétanque. He is in very good health and does not have many medicines in his home.
The only one he regularly uses is syrup for catarrh, since he used to smoke heavily.27
Yasumasa, 70, and his wife Nobuko, 66, in their bedroom. They live in the Honatsugi district of Tokyo, Japan. They are both retired
and have two sons, who visit with their families at weekends. Yasumasa has a heart condition, for which he takes multiple daily medicines
(seen in the small transparent sachets in the photo). Nobuko takes calcium for osteoporosis and aspirin for her heart.28
Noorjaha Sagri, 56, her husband Abbas Ali Sagri, 67, and, from left to right, their children Faisal, 24, Heena, 17 and Rafiq, 22. They live in a one-room flat
in the Dharavi slum of Mumbai, India. At night they pull out a mattress and all sleep in one room. The parents do not work, while the children do sporadically
and are the only source of income for the family. Abbas has suffered a stroke, so most of the medicines visible are for his use.30 FUTURE HEALTH
Arunas Andriejauskas, 53, and his wife Aliona Andriejauskaite, 52, in their home in Preila, Lithuania. Arunas is an engineer and Aliona
teaches science. They deeply believe in the curative powers of nature and do not use industrial pharmaceuticals. Instead they produce
their own remedies, foraging in the woods around their house for herbs, mushrooms, and berries and harvesting from their vegetable garden
and honey production. They have a large selection of essential oils that have specific applications for different ailments.HOME DISPENSARY 31
Isidro Flores Gonzales, 48, and his son Adrian Flores Mendoza, 25, in their house in Xochimilco, a borough of Mexico City.
Isidro is a biologist and founder of the conservation group Santuario del Ajolote, which tries to protect the axolotl,
a rare kind of salamander that lives in the nearby lakes.32 FUTURE HEALTH
Paola Agnelli, 62, and Roberto Galimberti, 68, with their cat Nina in their apartment in Castiglion Fiorentino, Italy.
They are both retired: Paola was a schoolteacher and Roberto a surveyor. Roberto suffers from a weak heart, for which
he takes enalapril and Xarelto every day, while Paola has had three operations to remove cancers and has to take Femara
(an anti-tumour drug) daily and Dibase twice a month, to counteract the negative effects of the anti-tumour drug.WHO WANTS
34
TO LIVE
FOR EVER?
By Rhymer Rigby
Advances in technology mean life expectancy is growing
rapidly – but are we all prepared for how living to 150
will transform and challenge society?36 FUTURE HEALTH
“How long would you like to live if you were
healthy – if you had the anatomy and physiology
of when you were 25?”
When people talk about longevity, they tend to focus on we re crazy – that it just doe sn’t happe n in biote ch for
the exciting scientific and social side of things – technol- early-stage assets.”
ogie s that e nable pe ople to live to 150 or e ve n 250.
Multiple careers. Families with eight living generations. This feeling of change in the sector has been helped by
But what about the business side of things? What is it like well-known individuals ranging from serial entrepreneur
to be working in the longe vity fie ld, and what are the Peter Thiel to Amazon CEO Jeff Bezos either investing
prospects for longevity businesses? in longevity-related businesses or making significant do-
nations to research foundations. As Bailey says, “This is
Juvenescence is a global biotech company that develops going to come as a big surprise, but ultra-high-net-worth
therapies to treat diseases of ageing and increase human individuals want to live longer – who’d have thought it?”
longevity. Dr Greg Bailey, its CEO and co-founder, says
he sees the commercial opportunities as being largely in Juvenescence’s own investors include everyone from fam-
improving old age. ily offices to financial institutions; there are roughly 120
in total. Although a doctor by training, Bailey has a long
“The goal of our company is to modify ageing,” he says. track record in the industry. This is his fourth senior bio-
“We are le ss conce rne d about incre asing your life span te ch company. Othe rs include Me divation, which was
than we are about improving your he alth.” The point, bought by Pfizer for USD 14 billion, and Biohaven, which
he continue s, is to incre ase your ‘he althspan’ – your trade s on the Ne w York Stock Exchange and curre ntly
healthy lifespan. The average lifespan in the developed has a market capitalisation of more than USD 4 billion.
world has increased enormously in recent decades, but
the ave rage he althy life span has not. In fact, in many The Bank of America has said it expects longevity to be
countries it is decreasing. We live longer, but with more a USD 610 billion industry by 2025. In a 2019 state -
years of ill health. ment, two of its analysts wrote, “Medical knowledge will
double e ve ry 73 days by 2020 vs. e ve ry 3.5 (ye ars) in
“Nobody wants to live to 120 if for the last 60 years of 2010, and ge nomic se que ncing costs have falle n
that you are in a wheelchair or have Alzheimer’s,” Bailey 99.999 pe r ce nt since 2003. This has e nable d a ne w
says. “So the question we’re asking at Juvenescence is: frontie r in pre cision me dicine to furthe r e xte nd life
how do you live healthily? How long would you like to live expectancy, heralding a ‘techmanity’ [technology meets
if you were healthy – if you had the anatomy and physio- humanity] revolution.”
logy of when you were 25?” Huge leaps in longevity tech-
nologie s are happe ning now, he adds. We are le arning The pre dictions for what an e xte nde d life span might
about the genes that control ageing and how to manipu- entail vary hugely. At the moment, the world’s longest-
late them, we are learning to regenerate tissue, and we live d outlie rs max out at just ove r 120. But change is
are developing better drugs. “This is going to take place coming. Profe ssor Sarah Harpe r of Oxford Unive rsity
so much faster than people think.” We are, he believes, recently said that a baby born today would be looking at
at an inflection point. an expected lifespan of 104 years.
He means this in a business sense too. “For the first time, We are also se e ing incre asing gains in life span, the
pe ople are re cognising that this is re al and capital is coronavirus notwithstanding. Between 2000 and 2016,
beginning to flow into this sector – and the more money according to the World He alth Organization, global
that flows into the sector the faster the technologies are e xpe ctancy rose by 5.5 ye ars – the gre ate st incre ase
going to develop. If anyone had told me that we would since the 1960s. This ope ns up a tantalising prospe ct;
raise USD 168 million in two years, I would have said you that the rate of medical advance means that if you canWHO WANTS TO LIVE FOR EVER? 37
make it to, say, 2050, you may be able to live more or less proper placebo-controlled clinical trials. “Our reputation
indefinitely. The biomedical theorist Aubrey de Grey has is everything. We would pull a product if we found out
suggested that some people already born will live for up the science wasn’t strong, even if it was making GBP 100
to 1,000 years. million a year.”
“I disagree with Aubrey,” says Bailey. “But I think 120 to But what about the social implications of all this ageing?
150 is on the cards for most people and that means we There’s a perception – perhaps aided by the interest of
have to sort out things like Alzheimer’s and Parkinson’s Silicon Valley billionaires in this area – that longevity is a
and arthritis or it’s not going to be viable . Right now, luxury good. In fact, this is unlikely to be the choice. “My
we’re working on the prevention of Alzheimer’s because first company madea prostatecancer drug, and 240,000
I think that’s more likely to be successful than treatment.” men in Europe will get prostate cancer – but 400 million
Alzhe ime r’s, he adds, is a difficult one be cause it has Europeans are going to age, so it’s a completely different
multiple causes, so a cure or treatment for arthritis is likely proposition,” says Baile y. “If the drug can be made for
to be found earlier. 5 pence, I don’t need to charge more than a pound becau-
se the patient population who can afford a pound a day
Juve ne sce nce , howe ve r, is not just about the type of is probably a billion pe ople globally, which of course
medicine found in hospitals. “Juvenescence is pursuing would translate to USD 365 billion per year, thus the Bank
standard pharmace utical products and IP-prote cte d of America number. But it will not be one drug; it will be
supple me nts or me dical foods base d on rigorous sci- a cocktail, probably unique to that patient or person.”
ence,” explains Bailey. “We have a division that is creating
young stem cells frozen in a simple syringe that could be The sheer breadth of what ageing and longevity cover is
used for someone who damages their lungs or for spinal ofte n surprising too. “We lice nse d a ne w te chnology
cord regeneration, but we will also sell products that are out of a university in January and it’s based on the fact
validated scientifically to protect your brain or your heart, that if you’re under the age of seven and you lose the tip
for example, directly to consumers.” However, he adds, of your finge r, in a significant numbe r of case s it will
the science behind these supplements will be based on spontane ously re grow,” says Baile y. “I think in pe rhaps
ALTERED INTRACELLULAR
COMMUNICATION
With age, cells increasingly transmit
self-preserving signals that contribute
to decline in tissue health. This is
STEM CELL EXHAUSTION GENOMIC INSTABILITY
related to diseases such as diabetes
Grey hair is an example of an One of the principal signs of
and atherosclerosis.
outward sign of ageing caused by an genomic instability is compromised
inward one; stem cells that have lost DNA repair. Chromosomes become
their ability to divide or replace those less stable with age, but are also
that have migrated, differentiated, or more affected by environmental
died. This is also linked to frailty and factors such as physiological stress
weakened immune systems. or disrupted circadian rhythms.
CELLULAR SENESCENCE TELOMERE ATTRITION
As cells age, they lose the ability to During the ageing process,
divide and grow, due to damage or telomeres, sections of DNA at
lack of necessary components. the end of chromosomes, are
They eventually stop completely in a
phenomenon called senescence that AGEING AS progressively shortened by the
process of cell division and become
increases the risk of carcinogenesis. A DISEASE prone to damage.
MITOCHONDRIAL EPIGENETIC ALTERATIONS
DYSFUNCTION Over time, changes in the genome
Cells lose mitochondrial integrity due of a cell occur through exposure to
to age and oxidative stress. This is a environmental factors, increasing
characteristic of diseases such as chromosome fragility and
Huntington’s and Parkinson’s. transcriptional noise in ageing cells.
DEREGULATED LOSS OF
NUTRIENT SENSING PROTEOSTASIS
The by-products of a functioning The process that regulates cell
metabolism damage cells, causing proteins declines due to exposure to
them to age faster. These molecules environmental stresses and can result
can affect our nutritional balance in Alzheimer’s, cancer, and diabetes.
and lead to age-related obesity.38 FUTURE HEALTH
“We are less concerned
about increasing
your lifespan than we
are about improving
your health.”
10 years’ time, we will have unravelled this ability to turn
on the switch in the body that allows you to regrow a limb
or an organ.”
The possibility this holds out is of people over 100 living
as if they are much younger because their worn-out parts,
such as kidneys, have been replaced. These parts will also
be ‘young’ – you will be getting a one-day-old kidney even
if you are 80. Humans, like cars, would be able to run in-
definitely as long as spares were available.
As for the wider business implications of millions of healthy
ce nte narians, the se are almost limitle ss. It will affe ct
e ve rything from human re production and pe nsions to
property and food production. “The key takeaway from
this is that what we have all thought of as crazy science
fiction is happe ning now: scie nce fiction has be come
today’s scie nce ,” says Bailey. “It’s going to have a huge
impact on a varie ty of industrie s, pe ople ’s live s, and
gove rnme nt policy – all in all it’s going to be ve ry dis-
ruptive but equally incredibly exciting.”WHO WANTS TO LIVE FOR EVER? 39
40 FUTURE HEALTH
A
41
HEALTHCARE
REVOLUTION
Technological advancements are having a profound effect in the world
of life sciences, with new therapies across a range of areas promising to
change healthcare dramatically.
By Janet Anderson
Life scie nce s are re volutionising he althcare by providing solutions Clément, President of BioAlps, an association that supports life scien-
whe re traditional me dicine is failing or simply too e xpe nsive . From ces in Switzerland, has been directly involved in the rapid emergence
ne uroscie nce , biote ch, and me dte ch to smart digital solutions, of the se ctor. “Whe n you think that our unde rstanding of the brain
life sciences cover a burgeoning new field with enormous potential. Take today is at about the same level as our knowledge of the heart 40 years
ne uroscie nce s as an e xample . Ne w the rapie s for age -re late d ago, this can only be the beginning of the revolution,” he says. To find
brain diseases and conditions such as Alzheimer’s and Parkinson’s are out more, over the next four pages we explore one of the world’s leading
alre ady e nte ring the marke t and re volutionising tre atme nt. Claude life sciences hubs...42 FUTURE HEALTH
LIFE SCIENCES IN
WESTERN SWITZERLAND:
MORE THAN THE SUM
OF ITS PARTS
BASEL
ZURICH
BERNE
CHUR
LAUSANNE
MONTREUX
GENEVA
LUGANO
Switzerland has emerged as the European leader in life sciences in terms of
scientific research output, biomedical patent activity, presence of biomedically
focused venture capitalists, and availability of human capital. Since the early
2000s, Western Switzerland has witnessed the convergence of biotechnology
and medical technologies to form what is today known as the Health Valley.
Thomas Bohn, Executive Director of the Greater Geneva Berne area (GGBa),
the official promotion agency for Western Switzerland, has been closely
involved. “This initiative was spearheaded and promoted by political
authorities and industry support organisations, as well as academics and
philanthropists,” he says. “Their vision and dedication have enabled Western
Switzerland’s life sciences ecosystem to become one of the most advanced
and most diversified in the world in just over 15 years.”A HEALTHCARE REVOLUTION 43
“At BioAlps we try to understand the globality of health and anticipate what is coming
next and prepare to be leaders in it. The future will be less about new drugs and more
about digital solutions, smart devices in the shape of wearables, mass data-driven
understanding of trends, the development of tailored treatments, and the
prevention of diseases on a global scale. The life sciences have the potential
to deliver health improvements across the globe.”
Claude Clément — President, BioAlps
1,000
INDUSTRY MEMBERS
varying in size
from one-man start-ups
to multinational
conglomerates
BIOALPS
BioAlps brings together
start-ups, universities, and
industry through regular
networking events.
SECTORS 100
Biotech INSTITUTIONS
Digital health including:
Medtech Research foundations
Science suppliers Universities
Incubators Technical schools
Investment funds Nursing schools
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