Young, Liberal, Silicon Savvy – Why did they join Juul?

Posted on | February 7, 2020 | 4 Comments

Mike Magee

In late 2018, young tech-savvy future entrepreneurs streamed into the offices of e-cigarette start-up Juul. Four thousand strong, they were attracted by the $38 billion valuation and the promise of stock sharing in the high-flying techie new business with moral cover – a mission to make cigarette smoking obsolete. At their Christmas party in the San Francisco Giants baseball stadium, all agreed, morale couldn’t be higher.

Nine months later, their vaulted CEO, Kevin Burns, formerly of Chobani, stepped down. Valuation had sunk by over 2/3s to $12 billion, leaving those sign-up stock bonuses highly devalued, and 16% of the staff were fired as the new CEO pledged to cut $1 billion. What happened?

Reality bit! Juul was a 2017 spin off from cannabis vape manufacturer Pax Labs. CEO Burns engineered aggressive expansion into Europe and Asia, sold a 1/3 stake to tobacco giant Altria, and embraced teen friendly marketing tactics and flavored pods. The latter delivered in more ways than one.

Yes, 1 in 4 high schoolers are now hooked on nicotine (1 pod has as much nicotine as a pack of cigarettes, and a 4 pod pack costs $15.99). But in return for massive profits, Juul is now public enemy #1 in the eyes of concerned parents, school boards and progressive legislators.

Juul has now pulled its ads and their most popular flavors off the market. But that’s not the worst of it. Over 50% of employees are tied up in an all-hands-on-deck effort to deliver to the FDA a “pre-marketing tobacco application” (PMTA) due May 12th that will expose ingredients, components, manufacturing processes, and health and environmental impacts of their product. As one anonymous employee posted, “We’re going to get the PMTA or die trying! Lol…do we have a plan b? No.”

The executive team has a Plan B – Hire former FDA Officials. That includes former lead toxicologist at the agency’s Center for Tobacco Products, Roxana Weil, and FDA tobacco inspector, Gabriel Muniz, who signed up recently as director of regulatory compliance.

It isn’t as if we weren’t warned. Back in 2018, Jonathan Winickoff, former chair of the American Academy of Pediatrics Tobacco Consortium, said: “Juul is already a massive public health disaster.” But others saw addicted adults, not kids as the real problem. David Abrams, former director of the Office of Behavioral and Social Sciences Research at the NIH, commented blithely “It changes your heart rate a little bit. The AAP is doing its job. And we should be protective of kids. But there are adult lives at stake, too.”

A recent executive order has put a temporary federal ban on flavored vaping products. But health advocates note that the pronouncement is filled with intentional loopholes. The West Coast workforce is predominantly Silicon savvy, young, liberal, and have one foot out the door. As one employee put it, “To be sort of beholden to Trump and Republicans for the existence of our industry is disheartening.”  

Coronavirus: Best Seat On My Flight?

Posted on | February 5, 2020 | 4 Comments

Mike Magee

Flights of US air carriers Delta, American and United to China have been cancelled until further notice, and travelers who have been in China within the past 2 weeks have had their entry into the US curtailed. But for the rest of us who are going to fly, what’s the the best spot to seat yourself?

Let’s put this specific virus aside for a moment, and share a few facts:

There are now more than 3 billion airline passengers a year worldwide, and spread of communicable diseases has been well-scrutinized including specific studies of SARS and H1N1 Influenza. Those studies revealed that coach-cabin passengers were at a 3.6% to 7.7% increased risk of contracting the virus if they sat within two seats of someone actively infected. Sitting in the first class lowers the risk, but only slightly.

Since these viruses are transmitted through the air primarily in droplets, or through touching contaminated surfaces, confined locations – whether crowded restaurants, subways, theaters, grocery store lines – all represent an increased risk. But one thing to note: Viruses prefer low humidity, and when you fly at 30,000 feet, you’re in a low humidity environment.

Most air travelers perceive the risk to be greter than it actually is because of misperceptions regarding air circulation. Modern planes utilize High-Efficiency Particulate Air (HEPA) filters, and compartmentalize their air return delivery system. That means that air collected in your immediate vicinity, after collection and filtration, is distributed back to your section. Translation, you are not continuously exposed to the germs of all the passengers. And your regional air is filtered 30 times per hour, removing 99+% of bacteria infections-treatment.com, fungi, larger viruses, and virus clumps.

So if you do decide to fly, what preventive steps make sense?

1.General: Clean hands, cover mouth when you cough or sneeze, avoid close contact with large groups. (Note: one study found that part of the risk of flying was in the queuing for boarding and disembarking; and after the doors have been secured but the ventilation system has not yet been turned on.) Facial masks are not currently recommended.

2. Limit movement: As much as possible, limiting movement limits exposures. Studies show that window seats are safer than aisle seats primarily because only 40% of window sitters get up from their seat during flight while 80% of aisle sitters are up and about. On the average flight of 3 to 4 hour flight, ½ of passengers never use the lavatory, and 40% use it once.

3. Your seat: Keep your hands clean and hydrate. Avoid seat back pockets that have stored tissues and who knows what else. If you are going to use your tray table, clean it with a disinfectant. Open your air vent fully and direct the flow to hit in front of your face. This creates air stream away from you.

4. Travel advisories: Check WHO and CDC sites for travel updates

5. Novel Coronavirus cases are fast approaching 25,000 with approximately 500 deaths or a case fatality rate of approximately 2%. Compare that with the 2003 figures for 8422 cases of  SARS and a case fatality rate of around 10%, and you can see why we’re not yet in a full blown panic.

6. Diagnosis and Treatment: Below is the best advice on surveillance and diagnosis from JAMA today adapted from the CDC. As for treatment, their is no vaccine as yet, and the effectiveness of anti-virals is as yet unknown but is being actively studied.

When The Wool Is Pulled Over Your Eyes (Again) … IT’s Not Exactly “Breaking News”!

Posted on | February 3, 2020 | Comments Off on When The Wool Is Pulled Over Your Eyes (Again) … IT’s Not Exactly “Breaking News”!

Mike Magee

In this age of hucksterism and “fake news”, we Americans need to accept the fact that we’re too easy a mark, too naïve, too corruptible. And don’t blame our elected leaders – they’re simply a reflection of us.

Just take a look at our health care system, overrun with profiteering, one of only two nations in the world that allows direct-to-consumer advertising, a world where a man like Arthur Sackler could be honored in the Medical Advertising Hall of Fame and have his name brandished on the top medical education conglomerates across the nation.

The fix we’re in is self-made and chronic. Consider the fact that tobacco companies (and that includes modern-day vapers like Juul) have been well acquainted with the profession for many decades. Through the 1930’s and 1940’s, when money was tightest because of the Depression, cigarette manufacturers were a major source of revenue to the two top medical journals in the country – the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine published by the Massachusetts Medical Society. Not only were they a major source of advertising revenue to these organizations, but they also were grand sponsors of the organizations’ medical meetings.

Cigarette companies have always been inventive and integrative public affairs marketers. And that was clearly evident at the time. Take for example how they played to the doctor’s ego in an ad in 1939 with the tag lines “Every doctor is a doubter”. The argument, straight from the finest minds of the finest PR agencies in New York City said, “If you advise patients on smoking – and what doctor does not – you will find important data in the studies listed below. May we send you a set of reprints?”

RJ Reynolds upped the “Public Affairs” ante on Philip Morris in 1942 by creating the Medical Relations Division (MRD). Not to worry that the MRD was directed by A. Grant Clarke who had no medical or scientific background whatsoever, but rather was in advertising; nor that all mailings were being processed, in and out, by the William Esty Advertising company.

Phillip Morris was an expected presence at the AMA’s 1942 Annual Convention in Atlantic City. Their convention floor exhibit drew quite a crowd, thanks in part to their ad in JAMA which solicited doctors to visit their on-floor, smoking lounge where they could “Drop in, Rest…read…smoke…or just chat.”

During those years, Philip Morris took a more direct approach. They placed themselves in the AMA and its members shoes, fighting for respect and autonomy, fearful of President Truman sponsored “socialized medicine”, and short on cash. Without even being asked, they ran a full blown public relations campaign on behalf of American doctors.

A wartime doctor ad in 1944 read: “He wears the same uniform. . . . He shares the same risks as the man with the gun. . . . Yes, the medical man in the service today is a fighting man through and through, except he fights without a gun. . . . [H]e’s a trusted friend to every fighting man. . . .[H]e well knows the comfort and cheer there is in a few moments’ relaxation with a good cigarette . . . like Camel . . . the favorite cigarette with men in all the services.”

Was the doctor being commended or exploited? One ad so effectively mines nostalgia, it could bring tears to the eyes of any doctor (including me) who has had to drag his tired ass out of bed in the middle of the night. It shows a pajama clothed, middle aged male, phone in hand, black bag an arm’s length away, ready for service, and the explanation: “24 hours a day your doctor is ‘on duty.’…When there’s a job to do, he does it. A few winks of sleep. . . a few puffs of a cigarette. . and he’s back at the job again.”

Health professionals, like elected federal officials last week, were targeted not for their individual buying powerful, but rather for their influence on larger group purchasing – whether that be tobacco or vaping capsules, or votes.

And its not that we Americans today are more ignorant than other peoples around the world, but we do seem to be remarkably slow at realizing we’re being played for suckers. “Not Willing To Hear Evidence” may have been last week’s dominant headline, but it wasn’t exactly “Breaking News.”  Burying our heads in the sand can have a cumulative effect. With Democracy, let alone health care, in the balance, it’s time to finally shake off our complacency, pay attention, seek the truth, and be responsible citizens of this great nation.

Tony Fauci Video On The Novel Coronavirus

Posted on | February 1, 2020 | 1 Comment

In this JAMA podcast, Tony Fauci provides a measured update on the novel coronavirus that jumped from animals to humans, its current severity, and appropriate public health measures underway. Listening time: 27 minutes.

Placing Coronavirus In Public Health Perspective

Posted on | January 29, 2020 | 2 Comments

Mike Magee

The big news this week is the new coronavirus spreading across the globe compliments of China. Prevention efforts are challenging and depend on limiting human contact with and transmission of the virus in a globally connected world. Even in the US, fear and panic spread faster than a wildfire.

In response to a single student at Arizona State University testing positive this week, a student written online petition stating, “The students of ASU do not feel comfortable attending classes due to the outbreak of the Novel Coronavirus. Until proper precautions have been taken to ensure the wellbeing of the students, such as disinfecting areas the student with Novel Coronavirus was present, ASU students want their classes canceled.”, garnered over 20,000 signatures.

Such communicable threats have always received outsized coverage compared to chronic preventable disease. Public health experts have struggled to accumulate the language and tools to provide a balanced view of the various health risks and threats to our human population.

As Starbucks and McDonald’s reactively close half their stores in China in response to China residents and visitors locking themselves indoors; and as US stock markets reel in response, let’s review some nomenclature that speaks to health and disease worldwide.

Two decades ago I keyed in on the work of Alan Lopez at the WHO and a young Harvard epidemiologist named Christopher Murray and their landmark work on the Global Burden of Disease. Murray is now at the University of Washington and heads up an independent global health research center called The Institute for Health Metrics and Evaluation (IHME).

When was the Global Burden of Disease report first published?

The Global Burden of Disease study was published in Science in 1996.

What did it examine?

It looked at the effect of disease not only on “lifespan” but also on “health span” for the first time. Investigators did so by moving beyond mortality rates and creating a new measure called DALY.

What is a DALY?

DALY stands for “disability adjusted life year” and is a measure that expresses one year of life lost (YLL) to poor health.

What is the difference between “lifespan” and “healthspan”?

Lifespan equals the number of years living, while health span equals the number of years of healthy living. These are two enormously different measures. We increasingly appreciate that disease and disability can significantly limit an individual’s productivity and happiness and radically alter individual, family and community well being.

Who was involved in the study?

The Global Burden of Disease study, begun in 1992, involved 100 collaborators in more than 20 countries. It attempted to quantify disease and injury burden of over 100 conditions and make projections out 30 years for 500 consequences or results of these conditions. In the analysis, over 50,000 estimates were made.

What is “dual burden of disease”?

Dual burden of disease refers to two different causative paths for disease and disability. One path is communicable disease, believed to be more prevalent in developing nations.  A second path is chronic, debilitating non-communicable diseases felt in the past to be restricted largely to developed nations.

Did the study project forward?

Yes. The study predicted that by 2020 heart disease worldwide would  achieve top billing, followed by depression, auto accidents, cerebrovascular disease and chronic obstructive pulmonary disease or emphysema.

Have there been any follow-up studies?

Yes. The Global Burden of Disease 2017 Project was reported out in Lancet, and continues to report targeted findings affecting the 195 participating nations on a regular basis.

What have been the study’s take-away observations?

1. Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability.

2. This family of diseases is associated with metabolic inflammation, that is a low-grade chronic inflammatory state which adversely effects gene-environment interaction. A focus on basic science research and personalized health behavioral solutions will be required to modulate this burden as world populations age.

3. In stressed developing nations, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden.

4. The rising burden from mental and behavioral disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems.

5. The US Opioid Epidemic has resulted in increased mortality and declining lifespans over the past 3 years, especially of white males, from suicide and homicides. This year’s results have flattened, but they remain below pre-epidemic levels. In addition, maternal and infant mortality in the US remains an outlier to comparator developed nations.

6. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets.

There will always be emerging threats like the current coronavirus that demand our attention. But, as Dr. Murray’s remarkable interactive online maps based on GBD data well illustrate, these pale in comparison to the modifiable threats contributing to chronic disease in our human population.

Johns Hopkins MBA Bets Future On Ever-Expanding Medical-Industrial Complex

Posted on | January 23, 2020 | 2 Comments

Mike Magee

What do you do if you are a highly ranked university, with one of the best nursing, medical and public health schools in the country, and applications for entry into your traditional 2-year MBA program have declined 14% over the past 5 years?

Well, the obvious answer is, you go out and hire a consulting firm. That’s what Johns Hopkins University did last year. The firm didn’t have to wander too far to diagnose the problem. They went to big employers and perspective (but hesitant) students and asked “What’s up?”

Students, according to the Wall Street Journal, “questioned the wisdom of taking two years out of a hot job market to go back to graduate school, especially if it requires taking on a large debt load to do so.” And employers said, give us “M.B.A.s with data-science and data-analytics skills.”

Alexander Triantis, dean of the Carey Business School at Hopkins noted that “There was a recognition that employer taste or needs for M.B.A.s may be changing over time and that prospective students may be sort of re-evaluating, based on the cost, based on opportunity cost.”

Clearly, rigor without relevance, especially at the cost of tuition and delayed opportunity, wasn’t going to cut it. So Triantis and his team went to the well.

Where Warren Buffett saw disaster (“Medical costs are the tapeworm on American economic competitiveness.”), the Dean saw opportunity. The MBA program, after all, doesn’t have a storied history or tradition dragging it down, like a Harvard, or Wharton at Penn, or Tuck at Dartmouth.  The Business School only opened in 2007, and its full-time MBA program is less than a decade old.  As a McKinsey consultant noted, “The M.B.A. marketplace was not behaving as it usually did coming out of the tough times in 2008.”

So what do buyers want. The consultant told the Hopkins Dean, “employers want to see an emphasis on science, technology and math skills in combination with softer skills like leadership.” Will it work? Time will tell, and much depends on whether the Medical Industrial Complex, which now consumes 1 in every 5 American dollars, will continue its wasteful and ineffective expansion.

If it does, Johns Hopkins program, designed “to capitalize on the university’s existing prestige in the medical field”, may be the place for you.  In your first year, you’ll have the opportunity to partner with a hospital chain or pharma company in data heavy “problem solving” – a statistical boot camp if you will. Over the next 24 months, your curriculum with be sprinkled liberally with health care case studies.

Patient focus? Not so much. But maybe that’s not the point. What is? As one student said in praise of the new strategic shift, it could be just what the doctor ordered, “especially as more big tech companies, such as Alphabet Inc.’s Google and Amazon.com Inc., pursue initiatives in health care.”

MLK, Cuba, and Trumpian Values.

Posted on | January 19, 2020 | 4 Comments

Mike Magee

We just returned from a 11-day trip with Road Scholars to Cuba. During the trip, Trump announced new restrictions on travel to the island. Last year’s elimination of cruise ships and flights to all cities except Havana shaved nearly 10% off tourism. The day of this latest offensive, a Cuban professor gave us a lecture on the Cuban American relationship over the past century. In closing, he mentioned that Martin Luther King was his hero and cited the “I Have A Dream” speech. He then said:

“I dream of the day my grandsons and your grandsons can travel to Cuba freely and play baseball together in a peace and love environment. I dream of the day when there is no blockade on the Cuban people, and Americans and Cubans can travel to Cuba and to USA without restrictions. I dream of the day when there will be a big bridge of  love  between our two peoples. I dream of the day when the light of love and friendship illuminates the sky that covers our two peoples. I dream of the day when violence disappears in the lives of our beloved sisters and brothers of the USA. I dream of the day when my people don’t suffer from shortages because of injustice and blockades. Yes, today I have a dream. God bless you.”

Throughout the 11 days, the most common phrase I heard from our fellow travelers was. “This isn’t what I expected.” Here’s why:

1. There was not a single sentiment of anti-Americanism expressed from anyone, anywhere, during the entire trip.

2. There was never a sense of danger or a single concern for safety as we freely explored rural and urban, cities large and small, alleyways and revolutionary squares, synagogues and churches, dance halls and schools. (Not incidentally, guns are illegal in Cuba.)

3. The joyfulness and constant expressions of love exchanged between and among the Cuban people was extraordinary, causing more than one observer to remark, “Why are Cubans so happy?”

4. The gratitude openly expressed to our group, by all we visited (approximately 50 different events/sites), was universal. They collectively and individually wanted us to know how much they appreciated our making the effort to visit them and support them.

5. Finally, since all of us in the group were grandparent age (and many had raised children and were active participants in grandchildren’s lives), there was common appreciation for the values these people embodied – a love of education, a belief in the healing powers of culture and the arts, a strong work ethic and remarkable resilience, love and loyalty to family, and finally – music everywhere.

This morning Captain “Sully” Sullenberger seemed to be channeling these values of resilience, courage and love in an Op-Ed in the New York Times titled, “Like Joe Biden, I Once Stuttered Too. I Dare You To Mock Me.” In the piece, he is primarily speaking to children who stutter and his advice includes, “Ignore kids (and adults) who are mean, or don’t know what it feels like to stutter. Respond by showing them how to be kind, polite, respectful and generous, to be brave enough to try big things, even though you are not perfect.”

Cruelty doesn’t cut it – no matter where you live. As many Americans have said, “We are better than this!” Our values and character as a nation are being stress tested. Hopefully we will stand tall, and embrace goodness, opportunity for all, humanity on our borders, and common decency.

As we reflect today on the life and values of Martin Luther King, consider visiting and supporting the people of Cuba. It is not what you have been led to expect.

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