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A Start-Up Suggests a Fix to the Health Care Morass

But perhaps the most interesting and potentially groundbreaking company created in connection with the Affordable Care Act is Aledade, a start-up founded in 2014 by Farzad Mostashari, a doctor and technologist who was the national coordinator for health information technology at the Department of Health and Human Services in the Obama administration.


Dr. Farzad Mostashari, the founder of Aledade, a start-up that seeks to reduce the cost of health care while improving patient treatment.

Andrew Mangum for The New York Times

Aledade, which has raised about $75 million from investors, has an agenda so ambitious it sounds all but impossible: Dr. Mostashari wants to reduce the cost of health care while improving how patients are treated. He also wants to save the independent primary care doctor, whose practices have been battered by the perverse incentives of the American health care system.

And here is the most interesting part: His plan is working.

A few weeks ago, I visited two primary care practices in southeast Kansas that have worked with Aledade for more than a year. Their operations had been thoroughly remade by the company. Thanks to Aledade, the practices’ finances had improved and their patients were healthier. On every significant measure of health care costs, the Aledade method appeared to have reduced wasteful spending.

“The whole idea is to align incentives between society and doctors and patients,” Dr. Mostashari said, adding that Aledade has helped reduce hospital readmissions and decrease visits to specialists in many of its markets. “We’re reducing unnecessary and harmful utilization and improving quality of care.”

Of course, such promises are not new at the intersection of health and technology. Many companies have made big bets and blown up — among them Theranos, the lab testing start-up, which turned out to have been more puffery than product. Aledade faces its own share of hurdles, including whether its investors can ride out a long and costly expansion before it starts to realize any big paydays.

Still, its plan — which mainly involves using software to achieve its goals — looks promising.

The American health care system is a fragmented archipelago, with patients moving through doctors’ offices and hospitals that are often disconnected from one another. As a result, many primary care physicians — who often see themselves as a kind of quarterback who calls the shots on a patient’s care — have no easy way to monitor a patient’s meandering path through the health care system.

Aledade’s software addresses that by collecting patient data from a variety of sources, creating a helicopter view. Doctors can see which specialists a patient has visited, which tests have been ordered, and, crucially, how much the overall care might be costing the health care system.

More important, the software uses the data to assemble a battery of daily checklists for physicians’ practices. These are a set of easy steps for the practice to take — call this patient, order this vaccine — to keep on top of patients’ care, and, in time, to reduce its cost.


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For example, say you’re a doctor at a small practice in rural Kansas and one of your patients, a 67-year-old man with heart disease, has just gone to the emergency room.

“In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” said Dr. Bryan Dennett, who runs the Family Care Center in Winfield, Kan., with medical partner, Dr. Bryan Davis. With Aledade, Dr. Dennett is now alerted immediately, so “we can call them when they’re at the emergency room and say, ‘Hey, what are you doing there? Come back here, we can take care of you!”

It is not just emergency room visits. Aledade tells doctors which of their patients is eligible for preventive care like vaccines or an “annual wellness visit.” The doctors said that during such visits they have discovered several conditions that would have ballooned into much bigger problems without treatment. The software lets doctors know when their patients have been discharged from the hospital, allowing them to schedule “transitional care management” visits.


Dr. Bryan Dennett and Dr. Bryan Davis are now alerted by Aledade to patient problems. “In the past, we’d only find out our patients were at the hospital maybe weeks afterward,” Dr. Dennett said.

Amy Kontras for The New York Times

Such visits are a gimme for the health care system — they have been proved to reduce hospital readmissions (which are extremely costly), and patients say they find them valuable in navigating the health care system. And because these visits are so effective at lowering overall health care costs, Medicare pays doctors a higher rate to provide such care — meaning that primary care doctors can make money by following Aledade’s alerts.

Yet even though Aledade thinks of itself as a technology company, its doctors said its software is the least interesting thing it does. Independent primary care doctors tend to be cautious about technology, especially if it seeks to thoroughly alter how they work. So the real battle Aledade faces is to integrate technology into doctors’ practices — and to do so in an nonintrusive and pleasing way. The software’s instructions must also prove financially rewarding for clinics, while still somehow saving money for the overall health care system.

To do all this, Aledade — which now operates in 15 states and has relationships with more than 1,200 doctors — has had to become more than a software company. It has hired a battalion of field coordinators who visit practices and offer in-depth training and advice.

The company has also taken advantage of several health care ideas that were introduced or accelerated by the Affordable Care Act. One of these is known as the accountable care organization, or A.C.O., which lets groups of health care providers unite to coordinate care for a patient. Studies have shown that such a structure lowers overall medical costs; under the Affordable Care Act, Medicare encouraged the formation of these organizations by promising to share any savings it realizes with doctors. Aledade took the accountable care organization idea and made it its primary business model. (The structure was reaffirmed by a 2015 law passed overwhelmingly by Congress, so a repeal of the Affordable Care Act would not have affected its structure.)


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For Aledade, the upshot is that it will only make a lot of money if it actually succeeds in reducing health care costs.

“Say Medicare thinks that it’s going to spend $100 million next year on our patients in Kansas,” Dr. Mostashari said. “A lot of this is from bad stuff — hospitalization, complications, you know, bad stuff. So we come in and say, if we can work with the primary care doctors to reduce bad things from happening while increasing quality, then we can save money for Medicare. Medicare says we thought we were going to spend $100 million on those patients, and we only spent $90 million. So, Medicare keeps half of the savings, and the other half of it goes to Aledade — which we split with the doctors.”

In addition to Medicare, Aledade has begun signing up several commercial health insurance companies under similar cost-savings plans. But given that the company gets paid only when it cuts health care costs (while improving health outcomes), Aledade and its investors are making a gamble.

In its first year of operation, for instance, Aledade managed to cut many costly procedures, yet its savings did not meet Medicare’s benchmark — meaning it realized virtually no revenue from the savings program.

The results for its second year are due in October. This time, because Aledade said its savings grow over time, the company is likely to begin making money. “We’re very confident in our model,” Dr. Mostashari said.

Email:; Twitter: @fmanjoo

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Sperm Count in Western Men Has Dropped Over 50 Percent Since 1973, Paper Finds

He noted that a 52.4 percent decline in concentration “may sound a lot,” but it represents a change from “normal (99 million sperm per milliliter) to normal (47 million sperm per milliliter).”

Still, Professor Pacey conceded in a recent interview that the new paper piqued his interest and represented “a step forward in the clarity of the data, which might ultimately allow us to define better studies to examine this issue.”

Possible causes

That the downtrend in sperm count is seen in Western countries suggests that “chemicals in commerce” are playing a role, Dr. Swan said.

While this survey did not focus on the causes of these declines, its authors pointed to existing research that showed that exposure to cigarette smoke, alcohol and chemicals while in utero, as well as stress, obesity and age, were factors in the drop.

“If the mother smokes, her son’s sperm count is decreased — that’s been shown in multiple studies,” she said.

A 2005 study, Dr. Swan said, showed that prenatal exposure to phthalates, also called plasticizers, affected the development of sons.


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Phthalates are a group of chemicals used to make plastics more flexible and harder to break. In several studies over the last two decades, they have been shown to disrupt the operation of male hormones like testosterone and have been linked to genital birth defects in male infants.

Dr. Swan, who conducted a 2008 study about phthalate exposure, said that scientists have had the ability to measure exposure to plasticizers only since about 2000, via urine. That has led to a 20-year lag in the process since researchers cannot enroll men to produce sperm until they are in their 20s.

That evidence is the “missing piece of the puzzle,” she said.

Professor Pacey cautions that while the changes in data may be driven by “greater exposure of pregnant women or adult men to more man-made chemicals,” it is too soon draw a conclusion.

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No trend studies were performed in the first half of the 20th century, said Niels Skakkebaek, a reproduction researcher at the University of Copenhagen, but in the 1940s, fertility doctors claimed that men should have at least 60 million sperm per milliliter to be considered normal and that many had more that 100 million per milliliter.

“Nowadays, average young men have 40-50 per milliliter,” he said.

Professor Skakkebaek, an author of a 1992 study that suggested chemicals play a role in the steady decline in semen quality, has since indicated that a rise in abnormal male reproductive systems may be linked to exposures to endocrine-disrupting chemicals.

“We must find out which ones are to blame for the problems with male reproduction, including male infertility and testicular cancer,” Professor Skakkebaek said.

The website for the Centers for Disease Control and Prevention says the effects from low-level exposure to phthalates are unknown, but it acknowledges that some types of phthalates have affected the reproductive system of laboratory animals and that more research is needed. The agency declined to offer further comment.

The National Institutes of Health also declined to comment on the research. The American Society for Reproductive Medicine did not respond to a request for comment.

The practical effects

Professor Skakkebaek pointed to Denmark and Germany as examples of how this course is playing out.


Figure reproduced from N.E. Skakkebaek et al/Physiological Reviews

“In Denmark, 8 percent of all children are now born after assisted reproduction,” he said. “In spite of this activity, the birthrates have for 40 years been significantly below replacement level.”


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“The number of young Germans have already declined 50 percent since the 1960s,” he said, adding that a similar pattern has been seen in Japan, which while not a Western country, is a developed one.


Figure reproduced from N.E. Skakkebaek et al/Physiological Reviews

In the United States, he said, the fertility rate among white people is “below the levels where the population can be sustained.”

Data about assisted pregnancies has been linked to women having children later in life, and in developed nations, statistics have shown that more women are choosing to have fewer (or no) babies, which may also contribute to the fluctuations.

Non-Western men

In the recently released research, no significant decline in sperm quality was seen in men from non-Western countries, but this segment made up only about a quarter of the results.

Dr. Hagai Levine, the head of the Environmental Health Track at the Hebrew University of Jerusalem, who led the team, said that one of the differences between Western and non-Western countries is that man-made chemicals like phthalates “became widespread much earlier in time” in developed nations.

Professor Skakkebaek said that reproductive issues among African men were less common: “It is already known that Africans have significantly lower rates of another testicular problem: testicular cancer.”

A study published last fall that looked at samples from just over 30,600 Chinese men asserted that semen quality and sperm count in the men had declined over a 15-year period ending in 2015 — with the percentage of qualified donors at a Hunan clinic falling from 55.8 percent to 17.8 percent in that time. To qualify, donors need to meet acceptable semen parameters including sperm concentration, sperm motility and semen volume.

“We urgently need international research collaboration to detect the causes,” Professor Skakkebaek said.

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Two human cases of West Nile virus found in Utah, health officials say

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Plague In Arizona, Amazon’s Pharmacy Ambitions, Drinking Health Effects

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End of US payments to health insurers would cause premiums to rise: CBO

WASHINGTON (Reuters) – Health insurance premiums for many customers on the Obamacare individual insurance markets would be 20 percent higher in 2018 if U.S. President Donald Trump follows through on a threat to stop billions of dollars of payments to health insurers, a nonpartisan congressional office said on Tuesday.

The Congressional Budget Office also found that terminating the payments would mean that 5 percent of Americans would live in areas that do not have an insurer in the individual market in 2018. However, the agency estimated that more insurers would participate by 2020 because they will have observed how the markets work without the payments and most people would be able to purchase insurance.

The CBO’s assessment echoes concerns raised by insurers over the past several months, who have said that terminating the payments would cause premiums to rise.

Trump has repeatedly threatened to withhold the payments, called cost-sharing reductions, which amount to about $7 billion in 2017 and help cover out-of-pocket medical expenses for low-income Americans. Trump has derided the payments as a “bailout” for insurance companies.

The CBO found that the number of uninsured would be slightly higher in 2018 but slightly lower in 2020 as more insurers joined the market. It also found that premiums would be 25 percent higher by 2020, which would increase the amount of government-provided tax credits to help shield low-income people from premium increases.

Several insurers have cited the uncertainty over the payments in raising insurance premiums by double digits for 2018 or in exiting some individual insurance markets.

Anthem Inc, one of the largest remaining Obamacare insurers, earlier this month scaled back its offerings in Nevada and Georgia and blamed the moves in part on uncertainty over the payments. Blue Cross and Blue Shield of North Carolina earlier this year raised premiums by more than 20 percent, but said it would have only raised premiums by about 9 percent if Trump agreed to fund the payments.

The payments are the subject of a lawsuit brought by House Republicans against the Obama administration that alleged they were unlawful because they needed to be appropriated by Congress. A judge for the federal district court for the District of Columbia ruled in favor of the Republicans, and the Obama administration appealed the ruling.

The Trump administration took over the lawsuit and has so far delayed deciding whether to continue the Obama administration’s appeal or terminate the subsidies. That case became more complicated earlier this month when a U.S. appeals court allowed Democratic state attorneys general to defend the payments and have a say in the legal fight.

The administration has decided month-to-month whether to continue the payments. Its next installment is due Aug. 21.

Trump has grown increasingly frustrated as Republicans, who control the White House, Senate and House, have been unable to pass a repeal or replacement of the Affordable Care Act, former Democratic President Barack Obama’s signature domestic policy achievement. After the Senate effort failed in July, Trump tweeted days later threatening to stop the payments.

The CBO estimated the federal deficit would increase by $194 billion from 2017 through 2026 if the payments are terminated.

Reporting by Yasmeen Abutaleb; Editing by Michele Gershberg and Chris Reese

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The collapse of Community Health Systems

Scott Paul, president of the Alliance for American Manufacturing, announced on Twitter that he is resigning from Trump’s Manufacturing Council. He follows the CEOs of Merck, Under Armour and Intel, all of whom stepped down yesterday.

Minutes before Paul’s announcement, Trump responded to the wave of CEO resignations on Twitter, saying he has “many” replacements for those who have left. “For every CEO that drops out of the Manufacturing Council, I have many to take their place. Grandstanders should not have gone on. JOBS!”

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Exclusive: India aims to revamp health scheme, lower costs after criticism

NEW DELHI (Reuters) – India’s health ministry has trimmed its cost estimates for extending its main public health program by 25 percent after criticism from a federal think-tank over inefficiency and slow progress, according to government documents seen by Reuters.

The new estimate of $25 billion for a three-year extension of the flagship health program, down from an initial figure of about $33 billion, comes as Prime Minister Narendra Modi pushes a multi-pronged agenda to revamp health services.

Planned reforms include streamlining spending and bureaucracy, slashing prices of life-saving drugs and medical devices, and nudging companies such as PepsiCo to make more healthy products.

To extend the National Health Mission to 2020, a think-tank led by Modi and the finance ministry in March told health officials to rework the original proposal with “realistic” budget expectations and to incorporate lessons from neighbors such as Nepal and Bangladesh, the documents show.

In response, the health ministry has resubmitted a plan with lower cost estimates and a list of targets to be achieved by 2020, including strengthening health infrastructure and reducing tobacco use.

The finance ministry, which will review the plan for approval this month, did not respond to a request for comment. The federal think-tank, NITI Aayog, declined to comment.

India’s National Health Mission is one of the world’s largest public health programs. It provides free drugs and treatment to millions of rural poor and helped to eradicate polio.

But the public health system is in a shambles and India ranks poorly on key indicators – more than a million children die every year before reaching the age of five.

After focusing on maternal and child health for years, the program will broaden priorities to tackle a growing burden of non-communicable diseases such as cancer, heart disease and diabetes, according to the documents.

The ministry has proposed increasing spending to treat such ailments from about $150 million this year to $1.5 billion in 2019-20, according to the new proposal which includes spending contributions from states.

The annual funding for strengthening the health system, including ramping up infrastructure and the work force, will more than double to about $3 billion in 2019-20, the documents show.

The new funding estimates are in line with a goal of raising health spending to 2.5 percent of gross domestic product by 2025, from 1.15 percent, a health ministry official said.


    Criticism, Revamp   

    The NITI Aayog was at first against the continuation of the National Health Mission, according to a record of government meetings reviewed by Reuters.

During a March meeting to discuss the proposal, the NITI Aayog’s health adviser said the program needed a “course correction” and needed to improve standards.

    The adviser, Alok Kumar, also pointed out that despite investment in the program, public facilities were not attracting enough patients, documents showed.

Because rural hospitals in India are often dilapidated and suffer from a shortage of doctors, it is not uncommon for people to shun them and travel long distances in search of quality healthcare.

In the reworked plan, the ministry has prioritized out-patient departments, and aims to reduce premature mortality from cancer or heart ailments by a tenth and cut tobacco use by 7 percent by 2020, the documents showed.

Kumar pointed out in the March meeting that Bangladesh and Nepal had performed “better with even lower resources”. Kumar declined to comment.

Data from World Health Organization shows that Nepal, for example, had an under-five mortality ratio of 35.8 per 1,000 births, compared with India’s ratio of 47.7.

Health officials acknowledged in the meeting that results had yet to achieve levels of neighboring countries.

Editing by Tom Lasseter and Robert Birsel

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6 foods that marketers want you to think are healthy

“Veggie sticks” shouldn’t take the place of actual veggie sticks — carrots, celery and cucumber. (Deb Lindsey for The Washington Post)

Y ou probably already know that real food is healthier than processed food. But sometimes it’s hard to tell what’s real because of the way foods are marketed. Once-healthy items such as vegetables, beans and nuts can become processed foods. Even if they start out as something good, what matters most is how they end up. Foods are manipulated and then advertised with words such as “healthy,” “real” and “contains vegetables” to make them sound more nutritious than they really are — but don’t be fooled. Here’s how some well-marketed processed foods compare with the real thing.

●Carrot sticks vs. “veggie sticks” : I’ve met many parents who think that “veggie sticks” (those strawlike chips made with vegetable powder) are the miracle they’ve been waiting for, because they can finally get their kids to eat vegetables. That’s because this snack’s packaging includes claims such as “made with spinach,” “now with sweet potato” and “100% all natural.” One brand even boasts that it contains the same vitamin content as 2½ cups of broccoli, seven cups of spinach, two carrots and more. Yikes. Please take heed: A tiny sprinkle of vegetable powder infused into a crunchy snack is not the same as eating a serving of vegetables. Veggie sticks are fine to serve as a treat, but they should not be confused with real veggie sticks — also known as carrots, celery and cucumber.

Most gluten-free breads have less fiber, protein and vitamins than whole-grain bread. (iStock)

●Whole-grain vs. gluten-free bread: Gluten-free foods were created for people with celiac disease or gluten sensitivity. But “gluten-free” has morphed into a marketing buzzword that people erroneously equate with “healthy.” According to a survey of more than 1,500 U.S. adults, 38 percent eat gluten-free foods because they believe they’re better for their overall health. But studies show that most gluten-free foods contain more fat and salt — and less fiber, protein and vitamins — than their gluten-containing counterparts. A dense, whole-grain sprouted bread made from fiber-rich, wholesome ingredients is a much healthier choice than a gluten-free bread made from fiber-free cornstarch, tapioca and rice flour. Gluten-free does not mean healthier.

Veggie burgers can be so highly processed that their health benefits fade away. (iStock)

●Hamburgers vs. veggie burgers: Plant-based diets are healthy, so it’s a safe assumption that a veggie burger is a healthier choice than a hamburger, right? Not always. Hamburgers can be as simple as beef and salt. Veggie burgers often have 20 or more ingredients, including nonnutritive cornstarch and thickeners such as methyl cellulose. And although beef burgers are naturally high in protein, most veggie burgers contain wheat gluten, a cheap protein substitute (and one that’s considered a potential contributor to the increase in celiac disease diagnoses in the past decade). Some veggie burgers are made of good-quality protein from beans, lentils and soy, but they may be so highly processed that the health benefits fade away. Read ingredient lists to compare brands, and don’t make your decision based on marketing words such as “vegan” and “all-natural.”

To get the ingredients of trail mix bars to stay together, manufacturers need to add something sticky and sweet. (iStock)

●Loose trail mix vs. trail mix bars: Good ol’ raisins and peanuts are perfect for a hike, and manufacturers have attempted to make this age-old snack even more convenient by turning it into a bar. The trouble is, to get the ingredients to fuse together, they need to add something sticky and sweet. Enter sugar. Whether it’s honey, maple syrup or agave, adding two or three teaspoons of sugar to your once-natural trail mix is never a good idea. The bars may come in packages emblazoned with words such as “natural,” “real food” and “nothing artificial,” but that tells you nothing about the sugar content. Plain nuts, seeds and dried fruit are a better choice than bars that contain added sweeteners.

Smartfood white cheddar popcorn has more than twice the calories of oil-popped popcorn and 525 mg of sodium. (Deb Lindsey for The Washington Post)

●Popcorn vs. “Smartfood”: Any food that has the word “smart” in it should ring alarm bells. If marketers have to convince you that it’s a smart choice, you should read the package carefully to be sure. In this case, popcorn is your better option. A three-cup serving of oil-popped popcorn has 126 calories, no sodium and just two ingredients. Three cups of Smartfood (white cheddar) popcorn has more ingredients, 290 calories and 525 mg of sodium. If you truly want to be smart, buy kernels and pop your own at home.

Baked potato chips often have more salt and starchy carbs than the fried kind. (iStock)

●Fried vs. baked potato chips: Marketing has led us to believe that baked snacks are healthier than deep-fried ones. A bag of baked chips boasts “65 percent less fat.” So what? That claim was powerful in the ’90s, when we were taught that fat is bad. We now know that’s not true, yet the claim persists. Here’s the skinny: In most cases, both types of chips have about the same number of calories, and the baked version often has more sodium to make up for the lack of flavor when the fat is removed. Plus, the baked version is higher in starchy carbs, which studies show are worse for you than a bit of vegetable oil. Although it’s not a health food, when you’re craving chips, go for a small portion of the real deal.

Registered dietitian Cara Rosenbloom is president of Words to Eat By, a nutrition communications company specializing in writing, nutrition education and recipe development. She is the co-author of “Nourish: Whole Food Recipes Featuring Seeds, Nuts and Beans.”

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Google Verily Unit Acquires Senosis Health

Quick Take

Tech giant Google (GOOG) has acquired digital health startup Senosis Health for an undisclosed amount, according to a report in GeekWire.

Senosis has developed a family of smartphone apps that monitor newborn jaundice, lung function and blood hemoglobin by using the smartphone’s camera and microphone.

Google is pushing forward on digital health initiatives through its Verily unit, and the deal likely fits into one of its core health platform initiatives as Senosis provides a range of technologies that can be scaled across the multi-billion smartphone installed base worldwide.

Target Company

Seattle, Washington-based Senosis was founded to capitalize on the increasingly advanced capabilities of smartphone sensors to assist in the measurement and diagnosis of a range of diseases.

Management is headed by co-founder and CEO Shwetak Patel, who previously founded technology startups that have been acquired by larger technology companies.

Below is a brief overview of Senosis’ HemaApp:

(Source: Paul G. Allen School)

Senosis’ has developed four smartphone-based apps:

  • Bilicam – Uses the smartphone camera to detect newborn jaundice
  • Spirosmart/Spirocall – Measures lung function by having user blow into smartphone microphone
  • HemaApp – Uses the smartphone camera to measure blood hemoglobin
  • OsteoApp – Uses the accelerometers to measure bone strength via vibrations

Notably, Senosis’ revenue model was a ‘pay-per-use’ model.

The company reportedly didn’t raise any venture capital, rather had secured $1 million from the SBIR program and was in the process of raising early stage funding when the acquisition was proposed.

Acquisition Terms and Rationale

Neither company has confirmed the deal or disclosed the acquisition price or terms.

Apparently, the deal is primarily for the technology and engineers, and not for senior management or founders at Senosis. Google hasn’t filed an 8-K, so I presume the deal was for a non-material amount.

Google has been interested in digital health for years but has little to show for that interest.

It currently has a simple application, called Google Fit, which is really just a fitness tracking app but one which can aggregate third-party app data for the user. So, Google’s main benefit so far has been integrating other technologies at a very basic level.

According to the report’s author, John Cook, Google has been investing more substantially in its Verily digital health subsidiary, and Verily’s CTO Brian Otis ‘also has ties to the University of Washington’ where Senosis has drawn a number of researchers.

Verily appears to be pursuing ambitious technology development initiatives along several vectors:

  • Sensors – Miniaturized CGM (Continuous Glucose Monitoring) and smart contact lenses
  • Interventions – Mosquito reduction, bioelectronic medicines, arm mobility, retinal imaging and surgical robotics
  • Health Platforms Population Health Tools – Healthcare performance measurement, chronic disease early detection and diabetes management tools
  • Precision Medicine – Multiple sclerosis observation, coronary heart disease, personalized medicine for patients with Parkinson’s, NIH precision medicine initiative and Project Baseline for research data

So, the deal for Senosis would like fit into Verily’s ‘Health Platforms’ group and promises to jumpstart Google’s digital health ambitions due to the wide usage of smartphones and Google’s capacity to scale solutions throughout the world.

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Disclosure: I/we have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours.

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Mental health and the media: when privacy trumps getting the story

For five days over late August and early September in 2016, a strange case gripped the Australian media. A family of five abruptly went missing from their rural property east of Melbourne. They left their house unlocked and all potential trace elements behind: phones, credit cards and identification documents. Keys were left in the ignitions of the remaining cars.

The alarm was sounded by one of the three adult children, about 24 hours after their disappearance, when he disembarked from what turned out to be an ill-fated road trip near Bathurst in central New South Wales, about 800km from their home. The two remaining daughters were quickly located after they stole a vehicle to escape; one of them later turned up in the back of a man’s ute – to the shock of the driver. Their mother was found the following day, wandering the streets of Yass, near Canberra; two days later, the father was discovered, safe but dehydrated, on the outskirts of the north-eastern Victorian town of Wangaratta.

The story became a viral sensation. “It felt like a variation on the Netflix show Stranger Things, itself a pastiche on missing people stories from the 1980s,” wrote Chris Johnston, a respected senior writer for the Age. “The strange gaps in the information also read like something out of The X-Files, with its protagonists fleeing from technology but tracked just the same.”

But the real echoes, he said, were closer to home. The road trip gone wrong was a common trope “straight from an Australian horror story”, with echoes of Australian cinema classics Walkabout and Picnic at Hanging Rock, of the legend of Burke and Wills, of foreign travellers stranded in harsh landscapes and unable to find their way home. Either way, the premise was identical: “City folk head into the bush and get lost, metaphorically and physically.”

Bizarre twists – that favourite tabloid phrase – abounded. Marnie O’Neill, writing for, suggested that the family might be suffering from a psychiatric condition known as folie à deux (madness of two) between the family’s husband and wife, which can in turn grip the children (folie à famille, a family madness). She wasn’t the only one to speculate that the family was suffering from some kind of delusional disorder, as experts were asked to weigh in.

These were some of the kinder interpretations. One website cut to the chase with its headline “The family that went mad together”. The Australian edition of the Daily Mail found a new angle by posting “eerie” photographs of the family home: “What happened inside the walls of this pretty farmhouse that drove the family out of their minds at exactly the same time?”

Finally, when all members of the family were accounted for, a statement was released: “More than anything, my family and I need time to recover and receive appropriate assistance, including mental health services,” it read. “To this end, we request that media respect our request for privacy.” The statement was reported with a photo of its author leaving a police station in a car, shielding his face from waiting cameras.

Six months later, Mamamia posted a smiling, undated picture of two of the family members, taken from Facebook, which purported to show them “moving on with their lives”. It was accompanied by a link to a Mamamia Out Loud podcast, where a group of women shared their theories about what went wrong after the “bizarre series of events”. The discussion begins with a breathless introduction:

OMG, can we please talk about the [name withheld] family mystery? Someone needs to call Sarah Koenig, seriously, this is the weirdest story. Can Sarah Koenig please make season three of Serial about this?

I’ve decided not to identify the family, although the story will be instantly familiar to many Australians and to anyone overseas who was following the news at the time. Personally, I avoided most of the reportage. It felt gratuitous, prurient. Beyond the immediate urgency of finding the family safe and well, everything else seemed like voyeurism. This was a deeply private matter and they were not public figures.

Whatever happened to them, it needn’t and shouldn’t define them in the public gaze any more than in the eyes of their extended family, friends and community – all of whom would have just been grateful and relieved to have them back. They have a right to rebuild and get on with their lives without the judgment or scorn of strangers, and without their name being reduced to a byword for craziness.

After all, I thought at the time, it’s no less than I would want for myself. Almost exactly six months before their disappearance, I headed into the bush and got lost too.


On the evening of 22 February 2016, I scrawled a note to my former partner, threw a handful of clothes and possessions in the car, and took off into the night. I didn’t know what I was doing, or where I was going: north, south, east or west. Somewhere along the way, I fired off three tweets that were unfortunately reflective of my state of mind before deactivating my social media accounts.

I drove all night, pausing only at a truck stop by the side of the highway to rest about 2am. The noise of the generators, and the adrenaline overloading my system prevented me from sleeping. I drove on, pulling up again in a country town, watching the sun rise from a sleeping bag on the local sports oval, then got back in the car and kept going.

By later that morning, the adrenaline had worn off, the car was labouring and I began to feel the weight of exhaustion, the magnitude of what I was doing and the distress I was causing for others. I switched on my phone, which was flooded with messages, called home and was persuaded to check myself into the nearest hospital. In between, my face was on the front of news websites. I’d been officially declared missing.

The model Naomi Campbell successfully sued the English tabloid the Daily Mirror after it pictured her leaving a rehabilitation facility. Photograph: Alberto E Rodriguez/WireImage

If I was sure I knew what was going on in my head at the time – and I’m still not – I wouldn’t explain it to you, much less why. I was, however, carrying lethal means of self-harm within the car, to say nothing of the fact that, while stone-cold sober, I drove a 28-year-old vehicle for more than 12 hours and close to 900km in a highly agitated and distressed state without sleep, food or water. By the time I was admitted to hospital, I’d barely eaten in 48 hours.

You could call it a cry for help or one long scream. It doesn’t matter: what does is that I didn’t follow through when I could have or, mercifully, hurt anybody else. According to Mindframe, which provides guidelines to the media about the reporting and portrayal of suicide and mental health issues, approximately one in five Australians will experience some form of mental illness each year. I’m far from alone.

This story, however, is not mine. It’s about how we talk about mental health and people in crisis, particularly in the frenzy of modern news reporting, when social media can and often does run ahead of the news cycle, when difficult ethical decisions are made in real time – often before facts are fully established – in an age of clickbait, confessional storytelling, declining revenues and minimal editorial oversight.

“Every time a journalist makes a decision around how to report on either mental illness or suicide, they’re making a judgment call based on the facts about the story that they have in front of them, so the application of the guidelines can be variable,” says Jaelea Skehan, chair of Mindframe’s media advisory group and director of the Hunter Institute for Mental Health.

Mindframe’s National Media Initiative began in 2002, with the aim of building collaborative relationships between the Australian media and the mental health sector to promote suicide prevention and to encourage accurate and sensitive reporting of suicide and mental health matters. It also conducts guest lectures in most journalism schools across Australia, including in compulsory law and ethics classes.

In the 15 years since, most media outlets have adopted conventions such as the listing of emergency hotlines at the bottom of stories. To avoid the risk of copycat behaviour, methodology is rarely mentioned; phrases such as “committed suicide” are avoided in favour of “taken his/her own life” – if suicide is noted at all. There is a fine line between breaking the stigma of an awful phenomenon that claims more than 2,500 Australian lives a year and glamorising it.

But reporting on what are complex and often unknowable circumstances, the warp speed of modern journalism, the concomitant time pressures on its practitioners, the amplification of social media and the capricious demands of editors who oversee different newsroom cultures and values all mean that the variability Skehan refers to occurs both across and within organisations, sometimes wildly.

Mental health exists at the interface of many different news stories: homelessness, for example. Photograph: Peter Parks/AFP/Getty Images

“Now more than at any previous time, when you talk about the media you have to ask who are you talking about,” says Margaret Simons, until recently the director of the Centre for Advancing Journalism at the University of Melbourne. “Nevertheless, leaping in and generalising, I would say reporting around the subject is better than it used to be but it’s still nowhere near good enough.”

She points out that mental health exists at the interface of many news stories: homelessness, for example, and domestic violence. She castigates Melbourne’s Herald Sun, which last summer ran a months-long campaign that cast a handful of people sleeping rough in the vicinity of Flinders Street Station as a public menace. “I think their reporting on homelessness has been disgraceful, particularly since they’ve also done some very good reporting on domestic violence. But they don’t seem to join the dots between the two.”

Mindframe, she says, has made a difference. “Particularly among younger reporters who’ve been through journalism courses in recent years; most of them would have been introduced to the complexities of mental health reporting. It doesn’t necessarily mean the culture of the newsroom supports them, or all of them are equally sensitive, or remember what they were taught. But at least they’ve had to think about it.”

Since Mindframe’s establishment, however, the social media revolution and the collapse of traditional media business models have meant the organisation’s best attempts at education are arguably lagging behind structural and institutional forces beyond its control. Similarly, the Australian Press Council, which regularly reviews its own material, has not updated its guidelines on health and medical reporting since 2001.

“I have definitely noticed that as I read mental health stories, I’m increasingly cringing,” says Melissa Davey, Melbourne bureau chief at Guardian Australia, formerly of the Sydney Morning Herald. She identifies two other pertinent issues: the loss or outsourcing of experienced in-house subeditors, especially from Fairfax’s ranks, and the diminishing numbers of specialist reporters.

It’s a sensitive subject for Davey, whose own family has been affected by severe mental health issues. She draws breath sharply when she brings up the case at the top of this story. “Everyone’s editors wanted to know what was going on there, and wanted approaches made to the family.” She attempted to make contact with one of them using Facebook’s Messenger service. She says it’s something she has dwelled upon ever since.


I caught up with some of the news surrounding my own disappearance in the weeks that followed. All of it was to some extent inaccurate, having been pieced together entirely from Facebook and Twitter. My partner had been advised by friends not to comment, particularly to television networks, so no one had much to go on. I read the stories with a sort of morbid detachment; I couldn’t afford to get too caught up in it.

One piece threw me, though. It was in the Daily Mail, and there at the top were screenshots of the three tweets I had broadcast (and later deleted) when in the middle of an emotional crisis. No link to helplines was provided. This was two months after the event: I’d come across the story accidentally, in the course of searching for an old article I’d written.

I looked at my profile picture and the awful words alongside it for several minutes, with an odd sensation of being outside and looking down on myself from a distance: the face, those words belonged to me, but I barely recognised them. What I recognised was that in writing them, I’d inadvertently cast myself as the Road Runner: I’d lit a firestorm on my trail, with coyotes in pursuit.

I emailed the journalist concerned requesting that the tweets be removed. The editor emailed back, noting that stories were normally not altered, but acquiescing seemingly on the grounds that I had asked nicely. They were replaced with an extra bullet point at the top of the piece: “There are reports he earlier posted a series of worrying tweets.” Helplines were added to the bottom of the copy.

Most other stories were well-intentioned. I was a missing person and the overriding concern was that I be found. It was hard to escape the feeling, though, that to some I’d ceased to be a human being: I was a story to be “got”. At least one piece referred to me in the past tense.

The publications to which I’m most grateful are the ones for which I do the most work, as they all decided not to report the story at all.

What to do, though, when social media is racing ahead of the news cycle? Such a frenzy, Simons says, “will have journalists acting both as participants and also feeding off it, and a lot of that can happen before [a situation is] even clear”. Engaging an online audience often extends to the moderation of comments on stories, the inclusion of which may be dangerously inappropriate in such circumstances.

Several sporting identities, including former Olympic swimmer Grant Hackett, have found themselves the subject of heavy public scrutiny in recent times. Photograph: Quinn Rooney/Getty Images

We have also become conditioned, in an age of overexposure, to want to know everything. (It’s perhaps worth pointing out here that a few editors were keen on what I’ll call the “Oprah” version of this story; naturally, a first-person tell-all would also have been cheap to commission.) “We can end up in a very precarious position where a story can quite quickly go from being in the public interest to not being in the public interest,” Skehan says. “We have this blend between traditional and digital and social media, and it means that people can forget when lines are being crossed.”

Every case is different, each presenting editors and journalists with a new set of considerations and complexities. And every media organisation faces another question, if it stops to ask itself this question at all: when to pull back? “At what point, when the initial story is over and the person is found, do we need to continue to stalk and hound and look for every single tiny detail associated with that story and try to summarise it in a headline?” Skehan asks.

This is especially the case when reporting on public figures. Sporting identities including the former Essendon AFL captain and coach James Hird, the former Olympic swimmer Grant Hackett and another celebrated AFL footballer, Lance Franklin, have found themselves the subject of heavy public scrutiny. All have received varying levels of support – or endured different degrees of intrusion.

Franklin, who took time away from the sport with depression (something that, in any other job, we would call sick leave), was treated with the most sympathy. Hird, who had been at the centre of a years-long scandal over the use of performance-enhancing supplements that eventuated in 17 players being suspended for 12 months, was admitted to a psychiatric facility in January 2017 after an overdose of sleeping tablets.

Hird and his family had learnt to live with media camped outside their home; now the cameras followed them to the clinic, where Hird’s condition was the subject of rolling updates as drawn-looking family members came and went. A familiar scene ensued: Hird’s wife, Tania, reading a prepared statement asking for the family’s privacy to be respected, in front of a scrum of cameras and microphones.

There is no common law tort of privacy in Australia, a subject that has been examined by successive law reform commissions. In 2004, years before the phone-hacking scandal, the model Naomi Campbell successfully sued the English tabloid the Daily Mirror after it pictured her leaving a rehabilitation facility, in a three-to-two majority ruling that Campbell’s right to privacy, in that instance, outweighed considerations of press freedom. “You could argue the same with the Hird case,” Simons says.

The Black Saturday bushfires threw up the thorny issue for journalists of gaining informed consent from people who were severely traumatised. Photograph: Catherine Best/AAP

Hird later wrote – by editorial request from the Herald Sun, but seemingly on his own terms – about his experience: “Everyone has a breaking point and I reached mine after years of continual stress … In 2002, I fractured my skull and required multiple metal plates in my head. I, for one, would prefer multiple skull fractures to the feeling of deep clinical depression.”


I have read Janet Malcolm’s excoriation of her craft (and mine) many times over. “Every journalist who is not too stupid or too full of himself to notice what is going on knows that what he does is morally indefensible,” reads the famous opening sentence of The Journalist and the Murderer (Knopf, 1990). Malcolm goes on to talk about the “catastrophe” suffered by the inquisitor’s subject:

On reading the article or book in question, he has to face the fact that the journalist – who seemed so friendly and sympathetic, so keen to understand him fully, so remarkably attuned to his vision of things – never had the slightest intention of collaborating with him on his story but always intended to write a story of his own.

It is the most uncomfortable truth any serious writer of nonfiction must acknowledge. This is not to say that journalists as a group lack empathy or consideration: “I think we get an incredibly bad rap when actually we really, really care about getting it right,” says Davey, and it’s obvious that she does. The point, though, is that a journalist’s first duty is not to our subjects. It is to our readers. I am no different.

In their study Black Saturday: In the Media Spotlight (Cussonia Press, 2011), Denis Muller and Michael Gawenda (Simons’ predecessor at the Centre for Advancing Journalism) examined the thorny issue of gaining informed consent from people who are traumatised. What practical meaning does informed consent have when the subject is in shock or distress? And how can a journalist assess the subject’s capacity in this regard? Survivors of the Black Saturday bushfires, they wrote, “described themselves as being in a kind of daze in which they were responding to questions while disoriented by a sudden and violent displacement, worried about the fate of friends or property, agitated by lack of knowledge of what had happened to their towns and communities”.

When a person is in crisis, comparatively little thought may be given to the state of mind of those closest to them. For 24 hours, my former partner – a private person with no media experience – found herself fending off inquiries and requests for photographs. At the same time she was trying to liaise with police, with no more idea than anybody else where I was or whether I was dead or alive.

Dr Stephen Carbone, leader of policy, research and evaluation at beyondblue, says anyone experiencing a mental health crisis is not going through it alone. “Their loved ones are going through the same emotional turmoil, particularly if they’re bereaved. It’s especially painful when people have been bereaved by suicide; it’s a very confronting and challenging type of death for people to deal with.”

Social media can and often does run ahead of the news cycle. Photograph: Alamy Stock Photo

Skehan says: “When someone is in a state of a distress and concerned about the welfare of someone else, then their cognitive abilities can be impacted. If media are asking them to comment, they’re actually asking them at a time in which they are incapable of doing it in the same way that they would if they weren’t in the current situation.”

On the other hand, as Simons argues, it is also the media’s job to help people tell their stories. This becomes particularly difficult when reporting on subjects with potentially reduced capacity: the homeless, for example. “Would the journalist be entitled to say, ‘I’m sorry, I’m not going to tell your story because you’re not in a position to make that decision’? That could be insulting, and equally ethically questionable.”

Then there is the issue of verification. Muller and Gawenda quote one frustrated reporter lamenting that the demands created by the 24/7 news cycle, and the insatiable appetite for it, means that “what is fact right now can be proven to be fiction 20 minutes later … Obviously there are some things we are going to, with all good intentions, publish that in an hour or two, or the next day, [are] going to be found to have been incorrect.”

Social media, of course, only stokes the blaze. Journalists, now trained to embed tweets in their stories, can find themselves updating reports from what is often little more than a rumour mill in close to real time, with precious little opportunity for fact checking. “It’s one thing if we know that a Facebook post has come from an organisation and that’s their statement; it’s another if you’re getting a bunch of random strangers speculating or making comments that we don’t know are true and then turning that into a story,” Davey says. This is exactly what ensued in my own case: without wishing to diminish anyone’s genuine care or concern, the effect was to turn smaller players into heroes while central ones, including my former partner, remained mute.

“If a person has disappeared, you’ll be updating it by the hour,” says Simons. In the case of the missing Victorian family, she says, “There were a lot of people reporting episodically, and gradually everybody became aware there were mental health issues involved. I think the tenor of the reporting did change a bit. But they were already a long way down the rabbit hole by then, and that’s partly the rolling deadline issue.”


In an essay for the Saturday Paper, Martin McKenzie-Murray explored in further detail the rare phenomenon of the folie à famille raised by Marnie O’Neill. He noted the police had refuted the wilder suggestions in relation to the family: of mob debts, drug-induced psychosis or cult membership. “What remained was a curiosity so intense we somehow felt entitled to resolution.”

We only had questions, McKenzie-Murray said, questions mostly responded to with speculation, which he then only added to. Eventually he admitted: “All of which is to say, we do not know. And perhaps that’s fine.” His conclusion is freighted with guilt: “Our curiosity turns people into puzzles to be solved, and people like me assume the role of solving that puzzle for readers’ entertainment.”

Johnston notes that the case was an extreme one and it’s unfair to generalise about the reporting of mental health based on it. In many respects this is true. But it also serves as a perfectly distilled example of how the institutional and structural pressures on journalists can very quickly lead them, and their readers, into places they may never have intended to go, and to things that were no one’s business to ever know.

Johnston acknowledged as much in a follow-up opinion piece. Stories about the family, he said, all “rated through the roof online”. And because there were few facts to go on, “the fantasies took hold”. Again, the piece was accompanied with a photo of the man at the centre of the mystery leaving the police station, protecting his face from view, proffering only a middle finger to the camera.

Leave me alone, it says.

Johnston was sympathetic. “They’ve had reporters – including us – knocking on their front door every day since last Thursday, but they were patient and understood they needed the media to help find their dad as much as the media needed them to try to explain to a growing mass of confused, engaged readers what had happened.” I respectfully disagree: while the media might have needed the clicks, the family owed readers no explanation whatsoever.

And did the family need the media? “With all due respect to journalists, it’s not their job to solve a missing persons case, other than if they’ve been asked to support the police,” Carbone says. “If you’re already half out of your mind with worry, the last thing you want to deal with is questions from complete strangers who obviously don’t really care about the person; they’re just after a story.”

Simons takes a more pragmatic view. “The police regularly turn to the media for help in finding missing people. I’ve been a journalist for 35 years; one of the main ways in which police look for missing people is to cooperate with the media in getting pictures and descriptions out there, and sometimes that can be very beneficial.”

The problem arises when such stories take on a life of their own. “It became clear partway through the saga that it was a very domestic, very intimate familial build-up of psychological issues that got the better of them, possibly briefly, in the end. Now it is up to the family to figure out how to go on,” Johnston concluded. I can relate to this. Psychological issues can get the better of any of us briefly, sometimes in terrifyingly destructive ways.

Such episodes, once experienced, become an inescapable part of one’s history: to be navigated; learned from; hopefully avoided; eventually accepted. If we’ve become the subject of wider attention along the way, we return to the world in the knowledge that it knows more about us than we might ever have wished it to. We put on our mask and get on with our lives, trying to resolve our inner battles behind closed doors.

We are all puzzles. Few people are as consistent as they appear, or would have others believe. We shapeshift; we project different versions of ourselves to our bosses, colleagues, partners and friends. Sometimes we lose sight of ourselves along the way. The puzzle of who we really are when we are most vulnerable is the missing piece of sky in the jigsaw that is hardest to complete. It’s also the most intensely private.

This is an edited extract from Missing Pieces by Andrew Stafford, Griffith Review 57, Perils of Populism.

In Australia, the crisis support service Lifeline is on 13 11 14. In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255

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