Future of China, Part III

I just spent two weeks in China visiting with families and friends. Mom and Dad took a trip with us to Hangzhou, Shaoxing and Thousand Islands. They are going strong.

The country is going strong as well. In Suzhou, the new subway connects east and west from the Industrial Park to the New Park through the heart of the old city. For a city with more than 2,500 years of recorded history, this sure is a milestone. Shanghai remains as one of the best connected cities I have visited. The transit at Hongchao connects airline, high speed train and subways, running as efficient as Amsterdam, Frankfurt or any other global hubs today. In Nanjing, construction cranes have disappeared from the skyline, and replaced are blue sky which were invisible in the last twenty years.

I also had opportunities to meet several friends who have returned from America to pursue their China Dream. Everyone of them were upbeat, and excited about new opportunities in the marketplace and in their careers. In healthcare, “the needs are so vast, you could almost work on anything and be successful!”, marveled by one, who is in venture investing. What most needed are talents. What a contrast with the medical device field in the US today.

The dissatisfactions were from friends never left the country. It is very difficult to conduct business without falling into the “gray zone”, where rules of law may not apply. The recent GSK scandal illustrated exactly the dilemma faced by virtually every business in China, multinational or local. This seems to me a classic example of the Game Theory. In a very competitive environment, if you follow the rules when your competitors do not, you are guaranteed to lose. When the law is not strictly enforced, everyone will be cheating. In China today, law enforcement is where power, interests and corruption convolute. The entire country seems to be screaming for the rules of law.

The future of China, a bright future of China, will come from institutions that can establish,  monitor and enforce the rules of law, which is the fundamental pillar of a democratic society. An early and an easy step is to establish the freedom of press. Microblogs and WeChat are making a difference already today. This will be a small step that will not destroy the stability of the country today, but free press will be a big step towards reducing corruption, a focal point for future concern. A next step is to seek independence of the judiciary system. The rules of law must be above anyone and any party. There is no replacement for the Chinese Community Party today. Many one party systems and countries have done well in the eastern culture. Having an independent judiciary system will help maintain the stability of the country, and lead to a better transition from an authoritarian state to a democratic state.

Future of China, Part II

We are near the 24th anniversary of June 4th student movement in 1989, and I almost feels that it happened yesterday.

It is the event defines my generation for our youth. When thinking about the future of China today, I still have a lot of reflections from thinking about June 4th.

There were many social drivers for the event in 1989. The country just begun a trajectory for dramatic improvement of living standard and productivity at the time; there were a lot of hope for better life in the future. What also begun at the time was the recognition of the unfair system associated with the one party system and the authoritarian state. Government corruption became a big concern, especially among students who began to compare China with other democratic societies that seemed to promote fairness and freedom for basic rights.

China has changed much since 1989. The Economist this morning reported that the country pulled 680 million people out of extreme poverty, and reduced its rate from 84% in 1980 to 10% now, accounted for three quarters of the world wide achievement over the period. Obviously a proud accomplishment for the Chinese people and the government.

Government corruption is still the focus of the Chinese microblogs today. The new Chinese government led by Xi also identified corruption control as the key for its long-term party’s ruling. The only difference on corruption from 1989 is that now it is everywhere. China’s last premier was reported with family wealth exceeded billion dollars. Environment pollution has reached the hazardous level that people dare the government officials to drink the water they regulate. Inequality has created new poverty issue that was different from when 80% people were poor versus many felt being leave behind by the system today.

Is this the time for Asian Spring?

In 1989, as a student, freedom and democracy were something to die for. 

Today, I think democracy is a tool for better society. Democracy, by itself, is not a goal for a revolution to throw a government away.

The recent changes in Egypt, Iraq, Afghanistan and Syria all told a lesson that the most important government function is to establish order. There could be far more damage come from lack of governance than from government corruption. Not having drinking water is very difference from having corrupted officials take money from water distribution, as untolerable as it sounds.

We all have experience when strong leaders are need to set direction and make decision for everyone to follow. That actually happens in businesses everywhere. Very few companies run on a democratic system, even though many employee may feel unfair treatment. We work in these entities because we agree that they align with our best interests. 

There are also decisions and choices should only be made through a democratic process. We don't want any one individual to decide on gun rights or gay rights. 

Comparing all government systems we have experienced collectively as a specie, democratic systems seem to yield the better outcome to minimize corruption, which is an inevitable byproduct from every power structure.

Is China ready for a democratic system today?

Future of China, Part I

Future of China, Part I

Witnessing changes over the Arab Spring and current affairs in Syria, I wonder what will be in the future of China.

In 1989, I was a college student in Shanghai. What happened during the student movement in China and what followed in Eastern Europe had many assemblance with the student protest in Tunisia, the transformation in Egypt, the collapse of the Gaddafi government in Libya, and the ongoing civil war in Syria.

It has been a wonder in the past 25 years in China for the unprecedented growth and the dramatic improvement in people’s life. Many wonder how could this happen in an authoritarian state. There have been suggestions that maybe an authoritarian state could be more efficient than a democratic one, maybe the state owned enterprises could be better aligned with long-term strategy than the short-term focus of western multinationals. Look at the chaos in the Middle East today, maybe the authoritarian state is better for today and tomorrow’s China.

I certainly hope tomorrow’s China is not the one governed by a party which does not recognize freedom for individual and democracy for all.

The recent reform in China began in 1978 with farmers wanted ownership of their land and reward based on their work. As a kid in the early 70’s, I remember almost everything was on a quota system due to short of supply. Our family of 6 had a monthly quota for 3 pounds of meat (I later heard it was good for the environment, which is fine, but it also explains why it is so hard to turn a middle aged Chinese into a vegetarian today no matter what the health benefit there is). By the middle 80s, the farmers markets were full of vegetables, chickens (without H5N1 or H1N7) and produces --- this came from the hard work of hundreds of millions of farmers simply making an honest living and a reasonable leader (Deng) who recognized that the government just needed to stay out of the way and gave back farmers their freedom to be owners of their land.

The Made in China status of manufacturer of the world started in regions that countless entrepreneurs took risks of leaving their jobs and put everything they had in new ventures that addressed every opportunity and need in the market --- every success story in Shenzhen, Suzhou, and Dongguan came from millions of migrant workers’ willingness to put in so much to improve their lives and a government willing to let market force to drive growth and development.

Aspiration for freedom and democracy has proven to be fundamental needs for every modern society, and it will be the future in China.

How will China transform from an authoritarian state to a democratic society without falling into the chaos in Syria today?

I want to imagine that in Part II of future of China.

Facebook Home

Facebook announced Home this week. I see this as another regression in social network driven by technology and marketing.

From the home screen of your mobile phone, Facebook “putting people first instead of apps”. We will be surrounded by friends in our social network as we listen to Thrift Shop, or watch the Final Four on a screen tonight..

This, indeed, represents a trend in the social network and media, what Ricky Van Veen called the identity creation. The motivation from experience first and documentation later (by picture and video) now evolves into documentation first lead to an experience in the social network later or in real time. On another word, we have finally caught up with Japanese tourists or Chinese tourists today, we must take a picture of everything for sharing.

The world through our friends’ len is a comforting one. We listened to Money for Nothing for the first time together. We speak the same set of languages and read books from similar authors. We did not experience any wars like our parents did, life is about personal fulfillment and career aspirations. We enhance these by sharing similar experience with our friends on facebook, reading tweets, blogs, and updates from the people we carefully select and follow.

We won’t be bothered by people cling to guns and religion, we won’t be upset by lyrics from Snoop Dogg, and we don’t have to think about lives for people spend less than one dollar a day..  

The world through our friends’ len is also a skewed one.

What we might miss, is the ability to make connection with people who do not speak the same language, and to seek out those connections in every new place we go. What we might miss, is to have a moment for just ourselves when we are truly touched by beauty, kindness, and peace.    

There is a Home, it is the place I want to return every day and to share with someone I love.

Better Sleep - Part II

The industrial revolution has made many changes in our life style. For example, one profound change is the abundant food supply that presented an enormous challenge on our genetic code of building up and storing energy for survival. The genetic evolution that built over millions of years could not adapt fast enough for the food revolution happened over a few hundred years --- this underlies the widespread obesity issue facing the world today.

Our eight to five work schedule has made similar impact on at least two other schedules of our daily life --- eat and sleep.

In trying to get to work before nine, I usually get up around 7. Breakfast is an abbreviated meal that I try to finish in 15 minutes. My wife makes an effort of packing lunch with leftover from last night, not ideal, but at least usually with plenty of vegetables. For dinner, as this is the only meal we enjoy as a family, by the usual dinner time of 7:30 PM, I am so starved that you have to yell at me to stop. In trying to keep with the new year resolution for better sleep, I go to bed around 11.

Overall, a pretty healthy lifestyle for a contemporary working man. Or is it?

I have been looking for answers for two questions:

One, is it better to eat three meals a day or eat four or five smaller meals a day? Two, is it better to have one consolidated sleep period from 11 to 7 or a couple of shorter periods, or is there a better schedule for each of us individually.

The sleep period is an interesting one. Eleven to 7 could be the best choice we have, given our work schedule, but it certainly is not for the longest living people on earth. Dan Beuttner in his book "Blue Zone" documented that the 80-, 90- or 100-year olds from the Greek island of Ikaria often party well into late night, sometimes mid-night. Then they get up whenever they wake up, eight, nine or ten in the morning. They often take naps in the afternoon, which is often a controversial topics among sleep experts. Some studies showed naps can improve neurocognitive function, and other experts consider any unconsolidated sleep --- sleeping during the day or in bursts is unsound.

Matthew Wolf-Meyer in his book "The Slumbering Masses" claims that our current model of consolidated sleep is not rooted in biology, but resulted from the relentless pressure for productivity in a capitalist society. He noted that American used to sleep in two or more periods throughout the day. They went out to bed not long after the sunset. Four or five hours later, they woke up --- praying, chatting, making love, and went back to a second sleep.

The biologic clock regulate sleep can be very different among us. Early birds and night owls are not only self claims but supported by models of sleepiness and wakefulness. Perhaps there could be another mobile health device to help figure out what is the best sleep schedule for each of us. You could measure sleep efficiency (for example, percent of sleep in the period of time in bed) when trying out different sleep patterns. After you have figured out when to take that best nap in the afternoon, you just have to get the carpenter who designed the desk for George Costanza.

I am still looking for answers on three meals a day...

Mobile Health Revolution - Understand Health Risks

Listening to the news on my drive to work every morning, the world is full of risks. This past week, it was the nuclear threat from North Korea. The biggest risk at the time of listening to this news, however, was in a moment of attention slip, I could hit someone's car, or similarly, someone else could hit me. Given the statistics from US census of 11 million car accidents in 2009, which resulted 36,000 deaths, it is a far bigger risk than dying from a nuclear war (0 death in the US history) or from a mass shooting (88 deaths in 2012), headlines of recent news.

Similar to the daily risk on the road, understand the daily health risk is also quite fascinating.

Jared Diamond wrote an interesting piece about our misperception about spectacular risks from events that are out of our control versus frequent small risks that we can control. The largest health risk facing by seniors may not be the mired of diseases associated with aging, it is that 1 in a 1,000 chance of a fall in the shower. For the 75 yr old professor Diamond, he figured that he needs to reduce that chance to be much smaller to survive from 5,475 showers to live to 90.


The mobile health revolution can help us be watchful to small daily risks that may become real dangers.


Bradycardia, or a very slow heart rate, is a condition common in seniors. It is often the cause for passing out momentarily or loss of consciousness. The occurrence of bradycardia is often intermittent and hard to diagnose. Just as dangerous of a slip in the shower, a fall due to a bradycardiac event is also the debilitating event for many seniors. A mobile health solution could monitor the event much more accurately than the clinic setting, and improve the ability to diagnose and provide appropriate treatment options.


Sleep apnea is another condition that occurs frequently, but varies night to night. The current diagnostic standard is to spend one night in the sleep lab or a one night home sleep test. A mobile health solution can help monitor the daily condition and tailor treatment accordingly.

The combination of these solutions may help us understand the overall health risk, be attentive to small daily risks, and be preventive to large events that send us into the hospital.

I am excited to see what Samsung’s new ‘S Health’ feature may offer.

Sleep Apnea Treatment Does Not Improve Neurocognitive Function?

The conclusion from the recent APPLES study was that CPAP did not improve neurocognitive function in sleep apnea patients. This study, conducted by some of the best scientists in the field, enrolled 1,516 subjects, followed a rigorous clinical trial design, came to a conclusion that surprised us all.

After 6 month comparison of CPAP versus sham treatment, in three measures of neurocognitive function including attention and psychomoter function, learning and memory, and executive and frontal-lobe function, there was no difference observed.

Unlike in cardiovascular clinical research, where large-scale randomized controlled trial is the norm to evaluate most treatments, it is rare to have randomized controlled trial in sleep apnea treatment evaluation. The APPLES study is probably the most rigorous trial to date to evaluate the standard of care --- CPAP.

There are abundant evidence of neurocognitive impairment associated with sleep apnea. In a systematic review of published literature, Dr, Ellen RL found persons with sleep apnea had 2 to 3 times car accident rate compared to those without sleep apnea. It also seemed to be clear that CPAP treatment could reduce car accidents. In another review, Dr. Antonopoulos CN showed CPAP use reduced car accident rate by about 20%.

What do these studies tell us?

There is a possibility that the association between sleep apnea and neurocognitive function is indeed weak as reported in the APPLES study. Our body may have incredible cognitive reserve to protect from sleep loss. These compensatory processes may be especially active during test conditions such as those used in the APPLES study. This is essentially the conclusion from authors of the APPLES study that sleep apnea is a multifaceted disorder and this study suggested the existence of a complex OSA-neurocognitive relationship.

The other big question is the effectiveness of CPAP, especially the adherence of therapy. The APPLES study did report on adherent adjusted outcome measures, which did not differ from main findings of the trial. Examining the adherence data more closely, there is a number that is quite alarming. In subjects with CPAP treatment at one month prior to the 6-month visit, the percent of regular users, greater than 4 hours per night for 5 nights per week, is 39%.

This has been the elephant in the room for sleep apnea patient care ever since the introduction of CPAP more than 20 years ago. Most patient could not adhere to treatment.

A study from Harvard Medical School and McKinsey estimated total economic cost of moderate-severe sleep apnea to be $65 to 165 billion annually in the US. We need to either improve adherence of CPAP significantly or to find new treatment options that are effective and much less intrusive for patient’s life.

Mobile Health Revolution - Killer Apps

There is a concern for the mobile health movement --- is this a hype? As seen in the recent interview of Dr. Eric Topol by John Nosta. The reason for the concern is the expectation of killer apps or home runs, and Dr. Topol did list a few. 

This is not different from the early days of internet or the dotcom era when the search for killer apps fed by funding frenzy that led to a bubble. Our experience with the internet has been one of an evolution over time, and a revolution after 15 years with many successes that offer valuable products. Google first appeared as a useful website to find information on the internet, which was limited at the time, and it was certainly not a revolutionary force changed our lives. Over time, its offers on search and map did become an integral part of our lives, a revolution completed. There are now so many internet services have transformed our lives, I am not sure if anyone is still try to conclude which are killer apps of the internet.

I believe mobile health will be very similar to the internet revolution. Initially, we will be looking for killer apps or home runs. Dr. Topol will have to tell the story of the airplane passenger saved by the iPhone ECG many times. This is also the time to ask questions about what issues/challenges faced by healthcare today can be addressed by mobile technology.  

It was fascinating to read the blogs by Dr. Janice Boughton on Why is American Healthcare So Expensive. Some of them are written like a nicely organized customer needs list when we began to design every new product in the medical device industry.  The challenges faced by Dr. Boughton everyday cry for better connection with medical information of her patients and devices that can help her in routine procedures so she can focus on cases truly demand her expertise.

I will resist the urge to ask or answer what are home runs so far for the mobile health revolution. The force of this movement is coming from engaged healthcare consumers wanting useful tools to manage their own health, is coming from early adopting healthcare givers embracing improved productivity, and finally is coming from payers need to dramatically reduce cost to make healthcare available and affordable for everyone.

Mobile Health Revolution - Lifestyle Change

We have made long strides in reducing mortality associated with cardiovascular diseases in the last 30 years. As a biomedical engineers, I would proudly attribute the success to ICD, cardiac pacemaker, and many other interventional procedures and new drugs that save lives. Once a while, there is an inconvenient argument that suggests the successful campaign on anti-tobacco use may have played as an important role as all of advances in medical technologies. That will be a difficult debate without a lot of data for cause-effect, but there is no debate that lifestyle is the most important factor that influences lifelong health.

In today’s calling to reduce overall healthcare cost, innovations that improve our lifestyle is also the biggest opportunity for mobile health solutions.

First to share a personal anecdote. I started to record daily weight about 10 years ago. After enough entries, I began to plot them, and monitored the trend more closely. To my disappointment, the weight did not drop. However, the standard deviation, or the day-to-day change, reduced overtime. The frequent monitoring provides a feedback to adjust diet, and remind me not to have that second piece of apple pie.

I see a good mobile health solution here. The App I am using today (‘My Weight HD’ or the FitBit system) provides some but an incomplete solution. I like to have a weight scale that sends data wirelessly to my cellphone after each weight. I need an App that provides simple tools to annotate, analyze and trend. This is a solution I would happily pay now, because I know it will help me keep a healthy weight, and avoid paying a lot more in the future in care for high blood pressure, diabetes, or sleep apnea. In the last 10 years, I did not lose any weight, but thanks to that little excel sheet, I did not gain any weight either.

The revolution in mobile health is in its solutions to empower healthcare consumer to be more knowledgeable about our own health, and provide tools for us to manage our own health. It is that one apple a day that keeps doctors away, one of the most effective way to reduce healthcare cost.

Better Sleep in 2013

Good sleep was elusive sometimes last year, as I spent many nights with colleagues in sleep labs monitoring patient’s sleep and conducting clinical studies.

My interest in sleep apnea spurs more curiosities about sleep. During the 2012 Sleep Society Meeting, there were still fascinating findings presented about fundamental roles of sleep. For example, lack of sleep greatly reduces our ability to synthesize learning from the day, an important trait from evolution of not forgetting animals almost killed us.

For many people, sleep apnea is the main obstacle from getting a good night sleep. It is the most common sleep disorders that affects 1 in 20 people. The easiest way to find out if you have sleep apnea is to ask if anyone witnessed frequent stops of breathing during your sleep. There are several questionnaires can be found on the internet (Epworth Sleepiness Scale, Berlin Questionnaire, and STOP-Bang) that evaluate symptoms of daytime sleepiness and risk factors associated with sleep apnea. Overweight and high blood pressure have strong connection with sleep apnea. There are many sleep labs available for diagnosis and treatment of sleep apnea. If a lab-based sleep study is too burdensome, the technologies for home sleep test are very good today, and are becoming a part of standard care.

There are also new development in treatment of sleep apnea in addition to CPAP, the standard care in the last 20 years. Dental devices for mild to moderate sleep apnea are gaining acceptance. These devices are less intrusive than CPAP, and are easier to use and maintain. Another efficient therapy that can be effective for some patients is positional therapy, which keep patients from sleeping on their back, the most vulnerable body position for occurrence of sleep apnea. This category includes devices from elaborate tennis ball approach (Rematee) to digital health solution (NightBalance). The Inspire Device and several other implanted neurostimulators in development target moderate to severe sleep apnea. We hope to report results from the ongoing safety and efficacy clinical trial in 2013.

So there will be better sleep in 2013 after wrapping the clinical study and done with watching others to sleep. The other aspects for better sleep, in the spirit of new year resolution, is to keep better sleep hygiene. I have a few for myself and more for my wife, who claims to be a night owl (I have found no scientific evidence for the genetic basis of an evening person)

New Year Resolution for Better Sleep in 2013:

1. Go to bed before 11, and
2. Keep TV, tablet and phone silent between 10 and 7

Unfortunately, the resolution is already broken for the year before it was written. They are still good rules to live by. Did you hear me?