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.