Chris Gibbons, MD, Johns Hopkins-Trained Health Equity & Digital Health Expert at The Greystone Group, Teams Up with StartUp Health to Champion Diversity in Medical Innovation
“In my mind, it’s time to take bold, new, innovative approaches. There is no better place to start than in the minds of those people who are made from the DNA of change, the DNA of challenging conventional norms — not just for the sake of doing it, but for the sake of overcoming problems that many other people believe to be unchangeable.”
A longtime advocate for technology in healthcare, Dr. Chris Gibbons’ research into our nation’s disparities and his belief in disruptive innovation as a necessary key for addressing health inequities offers insights about approaching the growing health crisis and achieving health for all.
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When did you come into the StartUp Health sphere?
About five years ago, KP Yelpaala and I initially met while we were both participating in a meeting about innovation and healthcare in Denver. Since then, we kept bumping into each other and then around 2020, I began working with the American Medical Association as an external advisor in the equity and innovation space. KP also became involved with this work. Later he introduced me to Unity who subsequently invited me to join.
What was the turning point in your career when you realized the role innovation and digital health play in the conversation around health equity? What was the spark?
There were a couple of sparks. The first came many years ago, just after my training at Johns Hopkins. I was doing a fellowship on The Hill at CMS (Centers for Medicare & Medicaid services) and data was beginning to show inequities in the United States. We’d heard about disparities in Europe, and minorities here kept saying there were issues, but most people here were either unaware or unbelievers. Congress asked that CMS evaluate the Medicare population to determine if disparities existed in this program, and if so, make recommendations about how to resolve them. We discovered that, yes, there were large gaps in the Medicare population. The US healthcare system is very fragmented and many people, from all backgrounds “fall through the cracks,” at one time or another. While some people can get back into the system, immigrants, minorities, the poor, and those with whom English is their second language often have more difficulty. We recommended the government explore the value of community health workers (CHWs) and patient navigators as a promising way to address this problem. In addition, we recommended that the government invest in computers and information technology to enable the development of a nationally viable CHW network because, at the time, most of these programs were largely disconnected from the formal healthcare system and paper based. So this prompted me to start thinking, “What would that technology look like and how exactly would it help these individuals?”
The second spark came right after that fellowship ended when I returned to Johns Hopkins to join the faculty and brought the ideas from the CMS research with me. My mind kept going to how to bring that technology to life. Shortly after returning to Johns Hopkins I learned about a meeting at NIH focused on a term I had never heard before: “eHealth.” I was captivated and although there were only about 50 doctors and scientists there, they were on fire. They were excitedly talking about the future, talking about technology and its role in medicine. I was blown away and decided this would be a big part of my future. What I didn’t hear, however, was anyone talking about the value of technology in improving the health of underserved populations. That day I decided that this would be the focus of my research. That was over 20 years ago and here we are today.
What are some of the numbers around disparities in health availability and outcomes for underserved communities that are present in your mind now?
It’s sad to say and for some, difficult to believe that it’s still true, but for most racial ethnic minorities and low-income individuals — and some of this applies to disabled groups and often even women, their experience can be summed up as follows — their health tends to be poorer, which means they are more likely to be sicker, and get sicker earlier than the general public. This happens not because they have a worse disease, or engage in more health-destructive behaviors as compared to the general public, or because they are naturally inclined to be sicker. It happens because they are more likely to be unable to receive timely healthcare services, because they are more likely to be affected by a variety of social, environmental, and economic factors prevalent in society, including implicit bias, prejudice, and racism, that have been shown to negatively affect health status and health outcomes. As a result, their health issues are more likely to be poorly managed or poorly controlled, and they are then at higher risk of dying more frequently and sadly, often earlier in life. As a nation, we have been systematically measuring these trends for more than a decade, and there has been no significant sustained improvement in these disparities at all. One year some may get a little better, the next year they get worse again, but generally, there has been no sustained progress, no matter what has been done.
For a long time, it was an issue people wanted to put under the rug, but you could argue that for the last five or seven years this has been a hot topic. Why do you think there has been no significant improvement at least over the last five to seven years?
First, these things took a long time to get to this place. There are complex sets of factors as to why we are where we are now. They are embedded in who we are as a nation, who we are as a people. We can look at the fact that one group does not have the same level of access to the healthcare system as another, and our solution can be to say, “Let’s open the doors.” What you need to recognize is that you can open the doors wider, but these groups are not coming through because they don’t trust you. And the reason they don’t trust you has to do with what else is happening in society, not just in the healthcare system. Some people have indeed been working hard, but far too many have not taken these issues seriously, even now. All these factors collectively lead to our inability to make sustained improvements. More people need to become involved. We should never confuse activity with progress.
You talked about the role the government plays in Medicare, Medicaid programs, these broad almost universal healthcare systems. StartUp Health is about empowering entrepreneurs to think differently, and hundreds upon hundreds of startups to think more about equity and taking on the challenges of health disparities. What do you think is the unique role of the global world of entrepreneurs in thinking about these issues?
This really excites me for a number of reasons. Let’s be honest, the government has had plenty of time to figure out how to fix these inequities and they just haven’t been able to do it. No need or value in blaming any one person or agency; it’s just the reality. Therefore, why would we continue doing the same things and expect a different result? And to be fair, it’s the same experience in Europe. They have been doing this longer than we have: established large, funded government initiatives to fix the same problem and have failed spectacularly, also. In my mind, it’s time to take bold, new, innovative approaches. There is no better place to start than in the minds of those people who are made from the DNA of change, the DNA of challenging conventional norms — not just for the sake of doing it, but for the sake of overcoming problems that many other people believe to be unchangeable. Someone once said, “Everything is impossible, until the first person does it.” I think this is true and a great challenge. The kinds of people who think this way are beginning to get involved and work on this issue in innovative and non traditional ways.
Is there a type of technology that gets you excited right now with its ability to reach new communities or close health gaps?
Here’s the analogy I often use. Let’s say for a moment I had a pill or procedure that could cure every patient’s illness. You’d say, that’s impossible, because nothing is perfect and there is no one pill or treatment that will fix everything. With that in mind, why do so many people think there’s one technology that will treat everything or fix health inequities? Just as we need not only pills, but other kinds of behavioral, psychological, surgical, or other types of interventions, a variety of ways of dealing with different people and their unique health concerns across their lifespan, I believe the same thing is true about technology. We will need a wide variety of technological and non-technological approaches to achieve better health or health equity. In addition though, we must start thinking differently about the healthcare system itself. It’s not only about reimbursements, insurance, and access to care, but we must think about what it is and, more importantly, what it should be in the future. Emerging technologies are reshaping norms and how people think about and interact with the world around them. This is what has to come to healthcare. That’s how we must start thinking about digital technologies and the impact they are having on consumer or patient health norms and values. We then need to design a new system, built on these new values, driven by new tech-based opportunities to achieve things that were previously impossible. Not trying to find “the one” but “the ones” that work, as well as who does each one work best for and how to put them together in an ecosystem that is itself equitable. I think this is a more useful and more appropriate way of looking at it.
We must have an all-of-the-above approach. There are some verticals, however, that might show more promise than others, whether it’s telemedicine or AI for “x” or digital therapeutics. Is there a sort of vertical you get most amped about?
There are certainly technologies I get excited about, and I think have great potential in helping us with these problems, but if we don’t roll them out properly, those same technologies will only make the problems worse, faster. If this is what we do, we’ll have a healthcare system that used to be all “in-person” that has gone virtual, digital, or hybrid. But the fundamental problems that caused the original problems will have remained unaddressed. In this system, we will have put digital tools in place that are only accessible to certain groups of people. They then reap the benefits while those who continue to be overlooked can’t, and the gaps remain or even get larger. And because data flows tend to move more quickly than people flows, we’ll likely know it faster. It’s not just about “a technology.” It’s about the right technologies used in the right way, to interact with real people in meaningful and appropriate ways that support their health journeys.
You bring up a good point about challenging the narrative around equity, and that you can’t just throw technology at it with that label and assume it’s going to work. Are there other ways you believe the industry could be getting it wrong?
Well, let’s look at this from the technology or solution development side of the coin. Unfortunately, 95–98% of the people who are developing technologies to address these problems don’t look like the people experiencing the health inequities. In most cases, these developers also have no expertise or significant experience working with these populations. This means it’s hard to envision how the assumptions they make about the design of their products can possibly lead to choices that result in products that are optimally designed for consumers and patients from diverse backgrounds. From my perspective, if we believe there is potential promise with these tools, then this is probably one of the biggest areas of change needed. On top of that, we all know it is really the products that get funded that get built. This brings up another problem that needs to be solved, if we are to make serious headway on this problem: who’s funding what and why, as well as who is not and why not?
Well, this is a big reason this issue is important to us. We’re such an early-stage investor, we’re often pre-product and the first investor, but what’s interesting about StartUp health is we’re trying to go further upstream and educate would-be founders and then invest in them. What are your thoughts about ways we can be strategic about going upstream and investing in the right people who understand the problems of underserved communities?
There are a few ways. Supporting people who can make an impact because they have lived experience within these communities, as well as individuals from these populations who also have innovation and technology expertise. We must involve these experts at every level of the design and development of these tools.
It’s also important to recognize that working with these founders and communities isn’t just “the nice thing” to do from the investor and purchaser side. It’s more than that. There is significant value from a health perspective. Here in the US we almost never attain most of our national health goals as articulated in the federal Healthy People initiative. We just keep revising them every five to 10 years and keep going forward. A big reason for this failure is because the people who are designing our health systems come from one part of the population, but a good proportion of those who are using these tools and systems are coming from somewhere else where they experience a different set of realities in life. Changing this will help us get there.
Finally, there is a lot of data now showing that focusing on equity — focusing on making your leadership as well as your rank and file more diverse — has large business benefits. We just worked with the AMA to produce a report on this, but I’ve seen others as well. It’s no longer just a nice or good thing to do. Reports show businesses that embrace diversity are more profitable, their products have higher customer satisfaction, and their margins are larger by significant numbers. Educating the current investor and purchaser group as well as creating opportunities for more people from other communities to become the venture and angel investors, or otherwise get into that very insular circle is vital. If we are serious about making change, those are some of the things we must do as a nation.
One thing that makes you unique in this conversation is you have been an academic and published papers about these topics. A lot of people have a lot to say publicly but haven’t necessarily put in the hours and done the research. What would you like to see studied next in this field?
On one hand, I feel we’ve studied enough and it’s time for us to act on what we know at scale. On the other hand, I realize there is certainly more we need to understand. There are plenty of people who do not come from the families, communities, or backgrounds experiencing these horrendous realities, but they want to do the right thing. They honestly, though, just don’t know what to do. They recognize they don’t have the background, skills, or perspectives, but they want to know and are willing to learn. Much more must be done to provide the evidence and insights about what to do and how to do it. Not just what the problem is. This information must be produced in a digestible form, not just in obscure medical or public health research journals. We’ve done some work along these lines in the past, but a lot more needs to be done. As we continue to study we need to make the relevant insights and new knowledge much more widely accessible and digestible by a much wider audience.
That’s a perfect summation: folks need a practical guide and I hope this health equity initiative helps do that. I believe that the 950 entrepreneurs that are part of our portfolio want to do the right thing and perhaps don’t have the right tools or wisdom to know what that looks like.
I agree with you. I believe that’s the vision of Unity Stoakes and others here, and those are the kinds of things that excite me about being invited to be a part of this process.
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