Healthcare

Global Investor 2.12, November 2012
Expert know-how for Credit Suisse investment clients
Healthcare
Entering the digital era
Bernardino Fantini It’s a long way from hand washing to the Human
Genome Project. Dr. Devi Shetty A visit with a cardiac surgeon who has
big ideas – and a bigger heart. S. Yunkap Kwankam How healthcare
is just a phone call away. José Gómez-Márquez Clever minds are hard
at work engineering better healthcare.

Read about pioneering technologies with our human body map
It’s with us all our life, but always seems to be changing and not
always for the better. That’s why researchers are developing
cutting-edge technologies to fix what was once thought unfixable.

GLOBAL INVESTOR 2.12 Editorial — 03
Photos: Martin Stollenwerk | Gerry Amstutz
Responsible for coordinating this issue:
Thomas C. Kaufmann joined Credit Suisse
Private Banking in 2006 as an equity
analyst for nanotechnology in the healthcare
sector. He is currently a senior equity
analyst responsible for global pharmaceuticals
and leads research on innovation,
one of Credit Suisse’s global megatrend
themes. Thomas has a Master of Science in
Biochemistry and a PhD in Biophysics, both
from the University of Basel, Switzerland.
Markus Stierli is Head of Thematic
Research within Private Banking Global
Research. His team focuses on longterm
investment strategies, including
sustainable investment and global
megatrends. Before joining Credit Suisse
in 2010, he taught at the University of
Zurich. Prior to that, he worked in market
risk management at UBS Investment
Bank. Markus holds a PhD in International
Relations from the University of Zurich.
Across the vast universe of modern global healthcare, probably the
single most important driver of change is information and communications
technology (ICT). Its impact may be slower and less obvious
than in fields such as entertainment or retailing, but it is gradually
revolutionizing healthcare. In this Global Investor, Denis Hochstrasser of
Geneva University Hospital and Hans Lehrach of the Max Planck
Institute explain how genomics is combined with other information to
create an avatar of a patient that can be computer-simulated to choose
the best treatment, as a computer model of a car or airplane can be
stress-tested. Eric Green of the US National Human Genome Research
Institute notes that the computer-driven development of genomics
and pharmacogenomics now forms the basis for treating asthma, AIDS
and some cardiovascular diseases. Turning to low-income countries,
S. Yunkap Kwankam of Global eHealth Consultants shows that text
messages are being used in African countries to collect and disseminate
data so as to direct midwives, doctors and medicines to the
right location at the right time, while José Gómez-Márquez at MIT
uses modern communications to help designers in low-income countries
produce innovative low-cost medical equipment. In the field of
mental health, where ICT is helping to raise awareness globally, Deborah
Wan Lai Yau of the World Federation of Mental Health explains her
pioneering work in China on rehabilitation via entrepreneurship, while
Ajay Mahal of Monash University and Victoria Fan of the US Center
for Global Development review mental health issues in India. Some of
these developments reduce costs, but many imply the need for more
funding. Naoki Ikegami of Tokyo’s Keio University explains how health
costs are controlled in Japan, while David E. Bloom and Michael Chu
of Harvard look at experience with privately funded healthcare in
low-income countries. To introduce all these themes, we begin with
an article by Bernardino Fantini of the University of Geneva, who looks
at the historical context, from some of the earliest work in connecting
diseases with specific causes (which allowed some of the simplest
but most powerful preventative measures, such as hand washing),
right through to the development of genomics.
Giles Keating, Head of Research for Private Banking and Asset Management
Global Investor received a gold medal at the 2012 BCP
(Best of Corporate Publishing) Awards – Europe’s most
important corporate publishing competition.

GLOBAL INVESTOR 2.12 Contents — 04
Beyond pills
Healthcare is more than the sum of its parts. In framing the articles
that make up this issue, we look beyond medical protocols and statistics,
and the particulars of financing. We introduce real humans who, like
Oscar Pistorius, have personally experienced both the distress of severe
disability and the hope that technology can bring, as well as innovators
on the ground who looked for practical health problems to solve and
did something about them. > Page 08 / 13 / 34 / 40 / 47
Medtech I
Double-amputee Oscar Pistorius says the summer of 2012 is
one he will never forget. That’s when he competed in both the
able-bodied Olympics and Paralympics in London, winning
gold in the latter, and a place in history in the former. Page 08
Economics II
Bindeshwar Pathak’s inventions are clearly not money thrown
down the drain. His Sulabh Shauchalaya twin pit is a pour-flush
toilet system that consumes about one-tenth the water of
conventional toilets and has done much to alleviate basic public
health problems in India. Page 13
Prevention III
Atul Gawande, the “New Yorker” writer who also happens to be
a surgeon, says the Hippocratic Oath – first, do no harm – can
best be kept when physicians realize they are human too
and make mistakes. “Getting the stupid stuff right,” as Gawande
puts it, makes the more complicated stuff a lot easier. Page 34
Access to healthcare IV
Advances in medical technology are not important if they can’t
reach patients, which is often the case in developing nations with
their poor infrastructure and isolated villages. The Schizophrenia
Research Foundation, an Indian non-profit, is trying to change
that by bringing psychiatric services to those in need. Page 40
Med 2.0 V
Physicians are now investigating whether IBM’s Watson
computer can help them sort out the vast amount of patient
information and data they increasingly face. If successful,
the computer could help suggest treatment approaches and
also warn of drug interactions. Page 47

GLOBAL INVESTOR 2.12 Contents — 05
Healthcare
09
From germs to genes
In the last two centuries, the application of reason and advances
in technology have taken the field of medicine from an art form
to a science. Bernardino Fantini reports on how researchers are
tackling the complex causal chain of diseases.
14
Private enterprise for public health
Private enterprise is contributing a growing share toward public
health as traditional models of healthcare do not appear capable
of delivering as they once did. David E. Bloom and Michael Chu
outline how private investors, entrepreneurs and the public
sector can work together to improve healthcare.
17
A prescription for growth
The pharmaceutical industry looks poised for a growth spurt
thanks to advances in molecular biology, genomics, biotech,
and bioinformatics, and according to Thomas C. Kaufmann,
these fields are yielding tailored treatments that promise
to be substantially more effective.
20
The “virtual” patient
Researchers are working toward developing the concept of
virtual patients. Denis Hochstrasser and Hans Lehrach say
these may be computer-simulated individuals, but their
conditions and treatments are very much part of the real world.
24
The genomic doctor is in
The human genome was first sequenced almost ten years
ago, but the work to interpret a code that is some three billion
“letters” long is just beginning. Eric D. Green explains.
26
The heart factory
Compassion and respect are the bywords where millions live in
poverty. As Bernard Imhasly discovers, that doesn’t mean they
don’t have access to first-class healthcare.
32
eHealth for all
Mobile telephony technology is assisting healthcare professionals
to deliver their services to remote and underserved regions in
Africa, says S. Yunkap Kwankam. He adds that information and
communications technology have transformed healthcare.
35
Japanese lessons
Healthcare expenditures have an inherent tendency to escalate.
However, Naoki Ikegami tells us that Japan has tackled the
issue of how to finance healthcare through its single-payment
system, which aims to contain costs.
38
Do-it-yourself tools for health
In resource-poor regions around the world, necessity truly is
the mother of invention. As José Gómez-Márquez reports,
when it comes to medical care, the dearth of appropriate medical
technologies in these areas has fostered the rise of ingenious
do-it-yourself tool design.
41
The neglected cousin
The rapid sociological and economic changes in India are
stressors that are increasingly posing a challenge to mental
health in that country. Mental health has, until recently, been
a neglected issue in India say Ajay Mahal and Victoria Fan.
44
Getting back to work
For those who have suffered from mental illness, reintegrating
into the workforce can be a daunting proposition. Deborah Wan
Lai Yau explains how social entrepreneurship plays a key role
in helping former patients make the adjustment.
46
Future of healthcare
Doing data mining and analysis, IBM’s supercomputer, Watson,
is working its way through vast volumes of healthcare information.
Jim Giles tells us it’s learning how to help doctors make
diagnoses. The ultimate goal: better care and lower costs.
Disclaimer > Page 48
Podcast on www.credit-suisse.com/globalinvestor

GLOBAL INVESTOR 2.12 — 06
The cost conundrum
Even nations such as Japan and the UK, long looked to as models, are coming under cost pressure.
A glance at the statistics reveals no obvious solution. In general, high healthcare expenditures suggest
higher life expectancy. Lower health expenditures appear to correlate with shorter lifetimes, though
not necessarily. Good healthcare is more than just a matter of money: above all, it requires new ideas.
India
65 years
55 USD
Japan
82 years
4,065 USD
Life expectancy
at birth, 2010
One ring = 5 years
Life expectancy at birth
indicates the average
number of years a
newborn infant would
live, assuming unaltered
conditions throughout
its lifetime.
Health expenditure
per capita, 2010
nominal (USD)
Total per capita health
expenditure is the sum of
public and private health
expenditures, divided
by the total population.
Cuba
78 years
607 USD
United States
78 years
8,360 USD

GLOBAL INVESTOR 2.12 — 07
Switzerland
82 years
7,810 USD
Russian Federation
68 years
525 USD
South Africa
52 years
650 USD
Burkina Faso
50 years
40 USD
United Kingdom
80 years
3,502 USD
Does more money mean better health?
Spending on healthcare (red) is loosely correlated to life expectancy
(blue). Rich countries tend to have high life expectancies. Life is
shorter in poor countries like Burkina Faso, where many die of malaria,
and in South Africa, where 17.8% of people are infected with
HIV. But many factors come into play. The question is not simply
how much money is spent on healthcare per capita. People live to
similar ages in Japan, the USA, Cuba, Switzerland and the UK. But
the UK spends 14 times more per capita than Cuba. Healthcare
spending as a percentage of GDP also does not explain a country’s
success. Spending is almost equal in South Africa (8.9%) and the
UK (9.6%), but the outcomes for health and life expectancy are
(91.5%) might appear to be the secret formula for a low-cost long
life. Yet the state also pays the lion’s share in the British system
(83.9%), which is nearly six times more expensive. Costs are also
high in the US system, where public spending amounts to 53.1%
of healthcare expenditures. Source: World Bank

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Beyond pills I
Technology in the fast lane
In 2012, Oscar Pistorius made history as the first amputee to
compete in the Olympic Games. Pistorius had been competing
in the Paralympic Games since 2004, when he won his first gold
medal in the 200 meters. Nicknamed the “Blade Runner” for
his artificial legs, Pistorius’ prostheses differ from what amputees
wear on the street and represent technological advances in
prostheses especially designed for athletes. His are from Icelandbased
Össur and work like springs. In fact, they are called
the “Flex-Foot Cheetah” and are custom-built prostheses made
out of high-performance carbon fiber.
Oscar Pistorius
Photo: Getty Images

GLOBAL INVESTOR 2.12 — 09
Medical milestones
From germs
to genes
The history of humankind is also the history of medical achievement. Aided increasingly by
technology, the last two hundred years in particular represent an astonishing array of intellectual
and practical breakthroughs in understanding the human body, the nature of disease and
how to treat it. Yet “health for all” remains an elusive goal that depends as much on wise and
effective public health policy as on medical innovation.
Bernardino Fantini, medical historian, University of Geneva
Listen to this article on Global Investor’s Knowledge Platform:
At the end of the first millennium (current era), human population
growth began to trace a steady upward curve that even the devastating
plague epidemics of the 14th and 17th centuries could only temporarily
interrupt. By the turn of the 19th century, the size and age structure
of populations – at least in the industrialized world – reflected a sustained,
fundamental alteration in living standards and longer lifetimes.
Today, life expectancy in developed countries has increased from 33
years two centuries ago to 80 years. In certain low-income regions,
however, life expectancy remains very low. And in some countries it
is even decreasing. In 1971, Abdel Omran coined the term “epidemiological
transition” to describe these demographic changes, which
result from socioeconomic developments and innovations in medical
theory and treatment over time.
In pre-scientific medicine, as in folk medicine, no link existed
between cause and effect. Moreover, so many different causes might
be evoked to explain a disease (air, food, bad behavior) that it was
impossible to propose a simple therapy for it. At the beginning of the
19th century, an influential school of thinking then current in Parisian
hospitals showed that to the contrary, diseases were unique entities
with specific characteristics associated with equally specific anatomical
lesions. These lesions could be distinguished by analyzing their
symptoms, identifying their clinical signs and directly observing them
in the bodies of patients at autopsy. Replacing the idea of multiple
causality with a single, specific cause changed the way knowledge
about disease is acquired and ushered in the age of scientific medicine.
In 1847, Ignaz Semmelweis discovered that an infectious agent transmitted
by midwives and doctors was the cause of high mortality in
maternity wards and could be eliminated by assiduous hand washing.
The London cholera epidemic of 1854 led John Snow to geographically
plot clusters of cases, which pointed to a public water pump as
the source of the outbreak . The revolution arising from
the work of Louis Pasteur and Robert Koch on “germ theory” rounded
out the explanation of the cause of disease. The theory suggested
that a contagious or infectious disease is due to the continued and
constant presence of a specific germ (micro-organism) that causes
disease in a person. That germ is the specific and necessary cause >

GLOBAL INVESTOR 2.12 —
01_
The London cholera epidemic of 1854, which ultimately killed 30,000 people, motivated physician John Snow to examine
the network of pipes and pumps that delivered water to the city’s neighborhoods. His now famous map plotting
mortality from the disease in an area of Soho showed that the number of dead was greatest near the Broad Street pump.
ARGYLL STREET
ARGYLL PLACE
MARLBOROUGH MEWS
GREAT MARLBOROUGH STREET
WORK
HOUSE
POLAND STREET
NOEL STREET
PORTLAND STREET
BERWICK
WARDOUR STREET
CARSLISLE STREET
SOHO
SQUARE
FRITH STREET
DEAN STREET
STREET
MARSHALL STREET
BROAD STREET
CARNABY STREET
KING STREET
PETER STREET
OLD COMPTON ST
GREAT PULTENEY
REGENT STREET
SILVER STREET
PULTENEY ST
STREET
LITTLE
PRINCES
KING ST
RUPERT ST
GOLDEN
SQUARE
BREWER STREET
ARCHER ST
STREET
GERRARD ST
WARWICK STR
Cholera deaths
Pump
of illness, even though other factors may also influence features of
the disease. Organic (i.e., constitutional), behavioral and environmental
conditions all affect exposure to germs and contagion. Koch’s “postulates,”
proposed in 1884, provided a logical, consistent way to establish
the causal connection between a microbe and disease.
New public health practices developed in the wake of this theoretical
innovation. Disinfection by heating made food such as baby
milk safe; inspired by Pasteur’s work, Joseph Lister introduced antiseptic
and aseptic techniques in 1869, which together with anesthesia,
changed the face of surgery by allowing access to the internal structures
of the body; serum therapy, such as that against diphtheria, and
especially vaccination made it possible to immunize organisms and
entire populations against specific germs. The development of microbiology
simultaneously sparked a theoretical transformation (“germ
doctrine”) and a social one (“medicalization of society”) through rapid
deployment of public health policy and generalized prevention
against endemic – i.e., regularly occurring – and epidemic disease.
Edward Jenner introduced the smallpox vaccination in 1796. Now, with
Pasteur’s famous experiments in vaccinating sheep against anthrax
and rabies in humans, vaccination became the prototype of a new
strategy in the fight against infectious diseases based on immunization.
The crowning success of this strategy occurred a century later, in 1977,
when the World Health Organization (WHO) declared the eradication
of smallpox.

GLOBAL INVESTOR 2.12 —
Photo: Cédric Widmer
In the first decades of the 20th century, a series of scientific discoveries
significantly expanded therapeutic options. The chemical industry
discovered aspirin (1899) and, in 1910, salvarsan, the first drug
against syphilis. In the 1930s, thanks to the work of Gerhard Domagk
at Bayer and the group of Ernest Fourneau at the Pasteur Institute
in Paris, sulfonamides offered effective treatment against a variety
of infectious diseases, in particular human African trypanosomiasis
– sleeping sickness – and leprosy. Working in the laboratory of
John Macleod in 1921, Frederick Banting and Charles Best isolated
insulin, which enabled immediate treatment of diabetics. Following
Karl Landsteiner’s discovery of blood groups in 1901, the first blood
bank was created by the Mayo Clinic in 1935. In 1928, Alexander
Fleming discovered that the mold destroying bacterial samples he
was working with contained penicillin. Its active agent was later
isolated in 1941 and tested on a small group of patients. The results
were striking, and large-scale production of penicillin became a priority
for the chemical war industry, along with DDT against the transmission
agents of malaria and typhus. In 1943, Selman Waksman isolated
another product from fungus, streptomycin. Its clinical effectiveness
against tuberculosis was quickly established, signaling, at long last,
control of the primary infectious disease of industrialized, urban society.
During and after the Second World War, a veritable explosion of science
and technology brought even greater change to medicine and public
health. Technology began to play an increasingly important role in
medical practice owing to medical imaging, microsurgery, intensive
therapy, transplantation, prostheses, immunosuppression and chemoand
radiotherapy for cancer. New disciplines, in particular molecular
biology, immunology and neurobiology, revised the theoretical understanding
of medicine.
At the beginning of the 20th century, Sigmund Freud’s discovery
of the unconscious profoundly altered thinking about psychiatric disorders
and spurred new therapeutic methods. The development of
neuroleptics resulted in drug treatments for these illnesses.
Epidemiology, which studies patterns of disease in populations,
also expanded considerably during the mid-20th century due to innovative
methods of investigation. The prototypes were the Framingham
Heart Study in the 1940s and, more recently, the MONICA Project,
sponsored by the WHO, which involves 41 collaborating centers around
the world. Both followed large groups of men and women to determine
the causes and risk factors of cardiovascular disease. Beginning in
1950, a study by Richard Doll and Austin Hill established the causal
link between cigarette smoking and lung cancer. The search for causal
links between different factors and diseases is also the aim of
so-called evidence-based medicine, which takes into account the
best clinical, scientific and epidemiological data in medical decision
making.
In the area of policy, two events signaled the postwar future, with
the creation in 1948 of the National Health Service in the United
Kingdom and WHO, which was the fruit of an international collaboration
in health that began with the first international health conference
in Paris in 1859. For the very first time in history, health was defined
as a fundamental right of individuals, and one of the essential components
of the stability and well-being that are the goals of humanity.
Bernardino Fantini
The molecular revolution of the 1950s and 1960s, which culminated
in the complete sequencing of the human genome in 2003, brought >

GLOBAL INVESTOR 2.12 —
“In succession, major
infectious diseases were
crossed off the list of
the ten main causes of
death in industrialized
countries, and were
replaced by so-called
degenerative or lifestyle
diseases.”
02_
In 2008, non-communicable diseases were the primary cause of death for
industrialized nations. Elsewhere, deaths due to heart and cerebrovascular
diseases top the list, but infectious diseases still figure largely.
Ischemic heart disease
Cerebrovascular disease
Trachea, bronchus, lung cancers
Alzheimer’s disease and other dementias
Lower respiratory infections
Chronic obstructive pulmonary disease
Colon and rectum cancers
Diabetes mellitus
Hypertensive heart disease
Breast cancer
Ischemic heart disease
Cerebrovascular disease
Lower respiratory infections
Chronic obstructive pulmonary disease
Diarrheal diseases
HIV/AIDS
Tuberculosis
Road traffic accidents
Hypertensive heart disease
Prematurity and low birth weight
0% 2% 4% 6% 8% 10% 12% 14%
Percentage of total deaths
High-income countries*
Low- and middle-income countries
* High-income countries are: Andorra, Australia, Austria, Bahamas, Bahrain, Barbados,
Belgium, Brunei Darussalam, Canada, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kuwait,
Latvia, Luxembourg, Malta, Monaco, Netherlands, New Zealand, Norway, Oman, Poland,
Portugal, Qatar, Republic of Korea, San Marino, Saudi Arabia, Singapore, Slovakia, Slovenia,
Spain, Sweden, Switzerland, Trinidad and Tobago, United Arab Emirates, United Kingdom
and United States of America.
a deeper understanding of the structure and function of genes and
their role in the development and functioning of the organism (functional
genomics), including susceptibility and resistance to disease. The
genetic basis of hereditary diseases, which are often rare and thus
forgotten, was clarified, opening up the possibility of “genetic therapy.”
These developments have led to efforts to identify individual differences
in how diseases are distributed and how they respond to treatment,
which may one day lead to personalized medicine.
In succession, major infectious diseases were crossed off the list
of the ten major causes of death in industrialized countries. They were
replaced by so-called degenerative or lifestyle diseases including:
cancer, cardiovascular diseases, metabolic diseases, accidents and
chronic diseases . National and international public health
officials believed that, thanks to mass immunization, health protection,
higher living standards, better food and safe drinking water, infectious
diseases would become increasingly rarer, and ultimately disappear.
The devastating polio pandemic that struck mostly industrialized
countries beginning in the 1940s did little to shake this confidence.
On the contrary, Jonas Salk’s and Albert Sabin’s rapid development
of effective vaccines and their immediate application quickly brought
the pandemic under control and reinforced faith in the ability of medicine
to deal with infectious diseases.
However, in the face of mounting challenges, critical examination
of epidemiological concepts showed that infectious diseases continue
to play an important role in human pathology. These challenges
include roadblocks to eradication programs, the evolution of drugresistant
bacteria, the emergence of new diseases – especially AIDS,
the arche typal disease of the late 20th century – and the re-emergence
of diseases formerly believed to be conquered, such as malaria,
tubercu losis and diphtheria. A list of 400 non-reportable diseases
that seemed to be occurring fairly frequently was established around
2000. In the future, disease must be thought of as a permanent,
recurring natural phenomenon. Moreover, it must be interpreted as
the result of Darwinian co-evolution between germs and human
populations. Microorganisms are basic to major physiological functions;
the human body contains ten times more bacteria than it
does cells. Humans and microbes are engaged in a symbiotic relationship
that, in a limited number of cases, becomes antagonistic
and triggers disease.
Newly emergent diseases are largely caused by environmental
and socioeconomic change. Consequently, taking an ecological and
evolutionary approach is critical in analyzing, explaining and mitigating
these diseases. The determining factors of health are many and are
linked to the quality of the environment, land distribution, habitat,
population density, relationships among individuals as well as social
hierarchies and finally, to cultural and moral attitudes that prevail at
any given time. Poverty, conflicts, social instability and economic
crises weaken populations and make them vulnerable to infectious
and chronic diseases.
Biomedical research has come a long way since the 1847 discovery
that rigorous hand washing could eliminate maternity-ward infections
transmitted by doctors and midwives. Today, the forefront of
biomedical research consists of integrating the diverse elements that
make up the complex causal chain of diseases, from individual genes
to populations. Combining a genomic approach to the study of human
populations and a spatial approach to the study of how diseases are
distributed and their social determinants would go a long way to
increasing knowledge and, consequently, the effec tive ness of medical

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Beyond pills II
Sanitation innovator
As many companies pursue the latest and greatest in advances
in high-tech medical innovations, one inventor has shown
that access to one of civilization’s most significant advances –
the common toilet – is key. Public toilet and bath facilities designed
by Indian sociologist and entrepreneur Bindeshwar Pathak use
only 1.5 liters to flush, compared to 10 liters for a conventional toilet.
They now serve more than ten million people daily in his native India
and are especially useful in water-poor regions. The design won
Pathak the Stockholm Water Prize in 2009 and is seen as a solution
for more than 2.6 billion people worldwide.
Bindeshwar Pathak
Photo: Sulabh International Social Service Organisation

GLOBAL INVESTOR 2.12 — 14
Health economics
By many measures, the world today is a healthier place than ever before, yet a daunting set of
deficits and disparities remains to be tackled. For various reasons, it is not clear that the traditional
tandem of government and civil society are up to those challenges. This creates an opportunity
for private enterprise to fill the breach. Indeed, evidence on the actual and potential contribution of
private enterprise to public health is growing.
health economist, Harvard School of Public Health, and senior lecturer, Harvard Business School
In recent decades, the world’s population has enjoyed astonishing
improvements in its health. Yet a daunting set of health deficits and
disparities persist, particularly for the world’s poor and vulnerable
populations. In the developed countries, life expectancy is 78 years,
while in developing countries it is only 67 – and in eight countries,
principally in Africa, it is less than 50. In developed countries, infant
mortality is only six per thousand, whereas in developing countries,
it is 46 per thousand. Spending on health varies too: high-income
countries spend more than 12 times as much per person as middleincome
countries and more than 75 times as much as low-income
countries. To make matters worse, in many of the world’s low- and
middle-income countries non-communicable diseases are on the rise,
including diabetes, cancers, respiratory problems and heart-related
conditions.
In development circles, these health issues are a grave concern:
sick populations undermine the economic power, social fabric and
political stability of society. They are also a source of frustration as
interventions appropriate to preventing or directly tackling the biggest
health risks already exist. The main challenge is getting those interventions
to chronically underserved populations. Fortunately, a new
source of hope is emerging – innovative and scalable private enterprises
that pursue health interventions that help poor people, perhaps
for humanitarian but also for business reasons. This raises the possibility
that developing countries can increase their reliance on private
enterprise and thereby benefit from its core expertise in delivering
goods and services to secure a higher standard of health. Indeed, the
interests of society are well served when both business and public
sectors deploy side by side, each doing what it does best.
Traditionally, the responsibility for protecting and promoting public
health has resided with governments, sometimes buttressed by civil
society (such as international development organizations and domestic
non-governmental organizations). Government has, in principle,
great legitimacy to operate in this space, as well as the reach to realize
scale economies, take proper account of positive and negative
spillovers, and design efficient and stable health insurance pools to
reduce financial risk.
In some countries, the public sector has performed well. In many
others, it has been unable to marshal the resources and political
wherewithal to do the job. Moreover, governments and civil society
are typically strapped for resources, and frequently inefficient due to
bureaucratic hurdles and corruption. These limitations of the public
sector (and civil society) have created large gaps that can be filled by
the private sector.
Already, private spending on health is significant in countries of
all income levels. In absolute terms, global private spending on health
in 2010 amounted to more than USD 2.4 trillion. While it varies signifi-

GLOBAL INVESTOR 2.12 — 15
cantly across countries, generally the share of total health expenditure
from private sources increases in inverse proportion to the wealth of
the country. As a group, private sources in high-income countries
account for 35% of all health expenditures (with the UK at just 16%,
and the EU at 23%). But in low-income countries, the corresponding
figure is 61%, with India at 71% .
The figures suggest that much of humanity frequently interacts
with the healthcare system by engaging in market transactions, exchanging
goods and services for payment. Low-income earners are
significant participants in this space. A recent attempt to quantify
healthcare markets for those with annual incomes below USD 3,000
(in local purchasing power) estimated the annual base-of-thepyramid
healthcare market at USD 42.4 billion in nominal dollars or
USD 158.4 billion in purchasing-power-parity (PPP) adjusted dollars.
The news here for the health sector investor world is that those
earning PPP USD 3,000 or less can constitute a sizable investable
opportunity .
Private enterprises for promoting public health are still in an infant
state. But the early evidence is promising, in part because both individuals
and governments are willing to pay for goods and services
that the private sector produces in the healthcare arena. And all
lower prices, better service and improved value proposals. The private
commercial sector is naturally attracted to opportunities with a potential
for profit. The application of commercial principles promotes
financial sustainability and provides incentives for continuous improvements
in efficacy and efficiency.
Of particular interest are new commercial models in healthcare
that meet the true test of business: revenues exceed costs – yielding
a surplus, the surplus is sustainable over time, and the surplus is equal
to or greater than the yield obtainable in activities of similar type and
risk. In other words, they are organizations that deliver high-impact
health interventions to otherwise underserved populations, while being
enterprises that are profitable and investable thanks to four characteristics:
Many thousands of villages globally are without the most
basic primary healthcare services, but there are hardly any that private
companies cannot reach via marketing and distribution channels. In
South Africa, BroadReach, a for-profit enterprise, has organized a
large network of primary healthcare providers that it supports with
training, clinical decision assistance and management systems. As a
result, providers can deliver advanced HIV/AIDS care and antiretro viral
therapy to patients who previously lacked access.
Take the case of penicillin, discovered
by Alexander Fleming in 1928. Ten years after the discovery, British
scientists Florey and Chain confirmed the drug’s therapeutic benefits,
but it was difficult to mass produce. Eventually the government recruited
the private sector to develop and implement efficient production
methods. Thanks to the efforts of pharmaceutical companies,
sufficient quantities of the drug traveled with the Allied soldiers to
the D-day invasion at Normandy. Shortly after World War II, penicillin
reached the commercial market to meet civilian demand – stopping
people from dying of strep, staph, syphilis and even tiny scratches.
. In India, Sulabh International invented a toilet system that is
inexpensive, environmentally safe and made with local materials. There
are now 15 million users of its public toilets and another 1.2 million >
01_
Share of health expenditure from private sources, as a share of total
health expenditure.
India 71
Bangladesh 66
Nigeria
Pakistan
Brazil 53
Indonesia 51
USA 47
China 46
Switzerland 41
Russia 38
Japan 17
United Kingdom 16
0% 25% 50% 75% 100%
02_
Lower prices, better service and improved value proposals benefit all.
Eastern Europe
Latin America
and Caribbean
Africa
Healthcare market USD billions (PPP)
Healthcare market USD billions (nominal)
Asia and Middle East

GLOBAL INVESTOR 2.12 — 16
of
in private homes. This initiative has helped to make other enterprises
commercially sustainable by creating 60,000 jobs in masonry and maintenance.
Similar undertakings exist in other countries.
In Mexico, free medical care and medicines are a
constitutional right. Roughly 55 million Mexicans (half of the population)
depend on the public health system. But the public health pharmacies
charged with providing free medicines supply them only 18% of the time.
In 1997, an entrepreneur established Farmacias Similares – a chain of
pharmacies with medicines priced at least 30% (and sometimes 75%)
lower than at traditional retail drugstores, with a doctor’s clinic attached,
charging about USD 2 per visit. Today, the chain has over 3,900 stores.
Every month, 12 million Mexicans use the chain to buy medicines,
and 3.5 million use it to see their doctor. After a seed investment of
USD 2 million, the chain now has annual revenues of over USD 1 billion,
with a net income in excess of USD 150 million.
In India, Aravind Eye Hospital has driven the break-even cost of
cataract operations to about USD 18, and Narayana Hrudayalaya
Hospital has achieved break-even costs for open heart surgery of
approximately USD 2,000 – thanks to world-class business processes
and cost accounting systems. Both institutions match or exceed the
quality levels of the leading US and European hospitals in their specialties.
These reduced costs suggest considerable opportunity for
expansion and replication because they permit these institutions to
earn substantial margins at the prevailing prices. For example, the
price charged by private clinics for equivalent open heart surgeries
is around USD 5,000 or more. In fact, Aravind and Narayana both
choose to use the surplus earned from their full-paying customers to
cross-subsidize lower-income patients. At Narayana, a total of 63%
of open heart surgeries are above break-even prices, while the remainder
are at or below break-even, including some absolutely free
of charge.
Exciting as the entry of the business sector into public health may be,
we are not suggesting that private enterprise can or should take over.
Whenever commercial healthcare models are developed, business can
scale rapidly and extend its reach at the lowest price to the consumer,
so long as competition remains open and intense. Simultaneously,
the public sector must continue to seek universal access to all those
high-impact health interventions for which no commercial models exist
yet. The government must also monitor and regulate to implement best
practices, and prevent abuse and fraud.
There are also certain needs that the private sector is not best
suited to address on its own, often necessitating a public-private
partnership. A good example of such collaboration is social marketing
designed to encourage adoption of a product or service by a target
population. In Tanzania, the Kilombero and Ulanga Insecticide-Treated
Net Project, implemented from 1996 to 2000, successfully used
social marketing to promote adoption of insecticide-treated bed nets.
Studies show that the donor-supported social marketing accomplished
more than commercial distribution alone might have.
The bottom line is that healthcare for all is an urgent global
priority. In this race to allow every human being to live up to their
potential, the new business models hold the promise that the glaring
gap between knowledge and action in healthcare may be significantly
narrowed by the financial might of private investors and entrepreneurs
– working closely with the public sector and the other major
Photo: David Carmack

GLOBAL INVESTOR 2.12 — 17
Pharmaceuticals
A prescription for growth
Over the past century, the pharmaceutical industry has experienced
several periods of rapid growth. Following what one might call a lost decade
for big pharma, the industry is now set for another growth spurt.
Thomas C. Kaufmann, Research Analyst, Credit Suisse
The origins of the pharmaceutical industry as we know it today trace
back to the second half of the 19th century, when a number of apothecaries
and chemical companies – mostly dye manufacturers – started
to focus their activities on the production and application of chemicals
for pharmaceutical purposes. Many of those firms have survived
in one form or another.
Researchers discovered that many diseases were caused by microbes,
and, building on the advances in chemistry and improving
microscopy techniques, the “microbe hunters” of the day searched
for the causes of many widespread illnesses. Around the turn of the
20th century, the search for cures was increasingly being conducted
in an organized manner, and compounds were chemically synthesized
instead of purified from natural sources.
Paul Ehrlich (1854–1915), a pioneer of modern pharmaceutical
research and Nobel Prize winner, was intrigued by the fact that
specific dyes tended to stain specific structures of the cell and postulated
that there is a relationship between the chemical structure of
a compound and its activity. He coined the term “magic bullet.” Ehrlich
was purportedly the first to systematically screen substances for
their therapeutic effect by introducing slight variations to a known
starting compound. His meticulous effort culminated in the discovery
of Salvarsan, a treatment for syphilis, which was endemic at the time.
In 1910, it quickly became the most widely prescribed medicine in the
world – a “blockbuster” drug in today’s terms.
The following decades gave rise to many important breakthroughs:
Insulin was isolated for the first time in 1921 from animal sources and
provided a treatment for a hitherto fatal disease. In 1928, Sir Alexander
Fleming discovered the antibiotic effect of penicillin, without, however,
further pursuing its clinical application. It was only during World War II
that concerted efforts were undertaken to produce the life-saving
drug on a large scale to treat wounded soldiers on the battlefield.
The dawn of molecular biology
This marked the definitive marriage between pharmaceutical sciences
and the chemical industry, and provided unprecedented scale. The
ensuing decades became years of rapid expansion for the industry,
as many major drugs were discovered and patented. In parallel with
this commercial activity, the structure of DNA was elu ci dated by Watson
and Crick in 1953. Some 17 years later, in another Nobel Prize winning
discovery, Werner Arber reported on the use of restriction
enzymes to manipulate gene sequences, heralding a new era. In 1978,
at Genentech, the first biotech company to go public, researchers were
the first to produce insulin by biotechnological means, i.e. using a host
cell to produce a human version of insulin, which until that time had
been isolated from cattle and pigs. The FDA eventually approved the
drug for commercial use in 1982.
Although many observers expected biotechnology to provide a
pharmaceutical industry around the millennium years were rather sobering.
Research & Development (R & D) productivity declined significantly,
as measured by the number of new approvals per R & D dollar
spent. The regulatory authorities asked for longer and larger clinical
trials to assess product safety, following the negative experience with
Vioxx, an arthritis drug that was discovered to be responsible for
numerous deaths only after being on the market for several years.
At the same time, most pharmaceutical companies were facing
patent expirations on their best-selling drugs and had several painful
setbacks in their development pipelines. A big wave of consolidation
swept through the industry, and large firms were increasingly looking
to acquire external pipeline assets from smaller biotech and pharmaceutical
companies to replenish their product pipelines. At the same
time, R & D expenditures were significantly cut at several companies
in response to declining success rates and considerable shareholder
pressure. >
01_Medicines in development
Due to advances in medical science, some 932 cancer drugs are being
developed – almost a third of all new medicines on the way. Source: PhRMA, USA 2011
HIV/AIDS and
related conditions
88
Alzheimer’s and
other dementias
98
Arthritis and
related conditions
198
Diabetes mellitus
200
Cardiovascular
disorders
245
Mental and
behavioral disorders
250
Respiratory disorders
Parkinson’s and
related conditions
36
Cancer
932
Rare diseases
383 460

GLOBAL INVESTOR 2.12 — 18
A recent examination of the “innovation deficit” of large cap pharma
revealed an interesting insight. A group at the University of British
Columbia looked at the regulatory approvals of drugs over the past
60 years in the USA and classified them according to their novelty
status. They made the observation that the number of true first-in-class
drugs that were approved every year exhibited only minor fluctuations,
whereas many of the drugs launched in the 1980s and 1990s were
follow-on products, or “me too” products. Thus, the recent decline in
approvals cited by industry observers is mostly due to a decline in
“me too” drugs. The underlying pace of true innovation has remained
remarkably stable.
Personalized and targeted treatments are on the rise
Photo: Martin Stollenwerk
Thomas C. Kaufmann joined Credit Suisse
Private Banking in 2006 as an equity analyst
for nanotechnology in the healthcare
sector. He is now senior equity analyst for
the global pharmaceuticals sector, and is
also in charge of research on the Innovation
megatrend theme. He holds a master of
science in biochemistry and a PhD in
biophysics, both from the University of Basel.
It has become more difficult to bring better products to the market
for indications that are already well-served by established drugs. The
low-hanging fruits have already been harvested. Nevertheless, the
ever-increasing understanding of the molecular causes of diseases
and the genetic variations among patients should lead to the identification
of many new targets and to more tailored (or “personalized”)
treatments.
Oncology is a prime example: the level of detail with which
tumors are characterized nowadays has contributed to a significantly
improved outcome for patients. The blood cancer drug Gleevec, from
Novartis, is often used to illustrate this. The drug is only given to
patients who exhibit a specific variation in their genome. It is in
this sense that the treatment is personalized. The resulting outcomes
for patients are truly stunning: with the introduction of Gleevec, the
five-year survival rate increased to close to 90%, compared to
30% previously.
This example shows how the understanding of the biology of a
disease is an important determinant of the level of success one can
expect from a treatment. In this context, it is not surprising that, in
view of the remarkable advances in the understanding of tumors, just
less than one-third of all medicines in development are geared toward
cancer. With the surge in molecular biology and the completion of
the Human Genome Project in 2003, the stage is set for other spectacular
findings. It is noteworthy that it takes 14 years on average to
bring a new medicine to market. Thus, today’s marketed products are
mostly based on biological insights that date back to the late 1990s.
In the meantime, a lot more has been learned.
Another very promising development has occurred in the area of
antibody-drug conjugates, as demonstrated by recent data for Roche’s
T-DM1 for the treatment of breast cancer. Basically, the idea is to use
an antibody’s specificity to direct a potent chemotherapy molecule to
the targeted tumor, and only to the tumor, so that the drug develops
its deleterious effect only at the desired site. T-DM1 has been shown
to dramatically reduce classic side effects, such as hair loss, which
arise from the systemic activity of conventional chemotherapy. This
is as close as one can get to the “magic bullet” Paul Ehrlich once
envisioned.
The combination of biology and chemistry around 1900 was crucial
for the successes of the pharmaceutical sciences in the 20th century.
Similarly, at the beginning of the 21st century, the disciplines of
biotechnology, molecular biology, genomics and bioinformatics could
provide an equally fertile ground for breathtaking advances in medicine.
While it is impossible to predict the exact timing of any future
breakthroughs, research requires patience, perseverance as well as
continued investment. As Louis Pasteur once said: “Luck favors the

GLOBAL INVESTOR 2.12 — 19
14%
7%
7%
43%
* The Pharmerging group consists
of China, Brazil, India, Russia,
Mexico, Turkey, Poland, Venezuela,
Argentina, Indonesia, South
Africa, Thailand, Romania, Egypt,
Ukraine, Pakistan and Vietnam.
** The EU5 group consists of
France, Germany, Italy, Spain and
United Kingdom.
Source: IMS Market Prognosis, May 2012
8%
10%
7%
19%
36%
20%
Rest of Europe
5%
Rest of the World
9%
North America
33%
12%
17%
Pharmerging*
30%
EU5**
13%
Japan
10%
2006
USD 658 bn
2011
USD 956 bn
2016E
USD 1175–1205 bn
A truly global expansion
Today, somewhat more than 10% of the
world popu lation accounts for roughly twothirds
of the worldwide pharmaceutical
market – a ratio that serves as an indication
of the theoretical expansion potential for
drug sales. This is expected to shift dramatically
over the coming years as emerging
market (EM) governments continue to
expand access to healthcare, and due to
a growing middle class that increasingly
demands state-of-the-art medical treatments
and is willing to pay for these out of
pocket. Emerging markets are currently
undergoing the same transition from acute /
infectious diseases to chronic /lifestyle
diseases as the leading cause of death, as
did developed markets in the middle of the
20th century. The adoption of a western
lifestyle leads to a rise in diseases, such as
diabetes, high blood pressure and cancer.
Already today, China is among the largest
markets for diabetes treatments.
Over recent years, pharmaceutical companies
have started to allocate significant
resources to emerging markets, in part to
overcome an increasingly challenging environment
in developed markets and in part
triggered by improved protection of intellectual
property. The expansion into EMs is not
only seen as an opportunity for significant
volume growth, but also as a means to tap
into the local talent pool. Most large pharmaceutical
companies meanwhile have R&D
sites in China, for example.
Even though governments in EMs are
striving to contain healthcare cost inflation at
an early stage, EMs nevertheless represent
a significant and welcome source of growth,
accounting for a growing share of sales.

GLOBAL INVESTOR 2.12 — 20
Big data
The “virtual” patient
Future and Emerging Technologies Flagship Initiatives aims
to use technological advances, such as the detailed analysis of
individuals’ genes and proteins, to contain healthcare costs
explain how.
Giselle Weiss, freelance writer
Giselle Weiss: How did the idea of the
Hans Lehrach: After I joined the Max
Planck Institute in 1994, I got involved in the
Human Genome Project. It was clear that
extremely important component of the medicine
of the future. By 2000, we had started
-
Why?
Hans Lehrach: Medicine is dangerous.
A virtual patient is easier to revive than
a real one. The average success rate of the
28%,
which means 72% of the patients who get
treated at a very high cost – EUR30,000
per treatment schedule – are actually more
otherwise. We need computers to help
Denis Hochstrasser is Director of the Department of Genetics and Laboratory Medicine
at Geneva University Hospital, Switzerland’s largest acute-care facility. He was a co-founder
Geneva Bioinformatics SA and Eclosion SA.
complex effects of drugs. Denis always
says …
Denis Hochstrasser: … that most people
would never get on an airplane that had
In 2000, in a landmark study, the US National
Institute of Medicine estimated that medical
44,000 and 98,000
US hospitals each year.
A follow-up study in 2006 reported that medication
errors in particular injure 1.5 million
people each year, at a cost of USD 3.5
Why has it taken so long to get to this point?
Hans Lehrach: We previously were
patient and every tumor. We didn’t have
-
But we were missing the detailed characterization
of the patient. Now that we have
What specifically could a model tell you?
Denis Hochstrasser: Take a patient
with leukemia. By comparing the patient’s
healthy genome with that of one of the
cancer cells, the model might suggest de-
through treatment. And a model of the
patient’s liver could indicate which drugs
Do you really need a computer model to do
that? Can’t you just rely on experience?
Denis Hochstrasser:
two or three things, not a thousand.
We get swamped. Computers don’t. And
today, we are inundated with information.
In the old days, a physician would slap
an X-ray up against the window to read it.
Today, a typical scan produces many slices
that are hard for a human to analyze
looking. I still see patients, and doing
hospital rounds involves consulting thousands
of PDF
Hans Lehrach:
-
that interact and do what you expect them
to do in reality. If you were modeling the
you would assume that sometimes they
speed up or crash. For the virtual patient,

GLOBAL INVESTOR 2.12 — 21
Photos: Thomas Eugster | Cédric Widmer
we model physiological interactions and
mental
components of the organism.
What will the virtual patient look like?
Denis Hochstrasser: There are
USA, uses personal health
information to visualize three-dimensional,
interactive anatomical models of individuals
that run on the iPad or iPhone. Nhumi,
a spin-off of IBMware
plug-ins for displaying virtual human
physical exercise and having your avatar
your medical history and genomic makeup.
The virtual patient is actually part of
a larger project called ITFoM (Information
Tech nology Future of Medicine) that is
competing for funding from the European
Hans Lehrach: In Europe, we spend
around 11% of GDP on medical treatment.
of aging societies. Moreover, people
at the same time they stopped working
under Bismarck. And as we are finding out,
longer living does not necessarily translate
into healthier living. We have a very strong
economic incentive to try and change
the healthcare system.
It’s going to take an enormous amount
of computing power, isn’t it?
Hans Lehrach:
of a weather report for 500 million Europeans.
We know that, for every patient coming
tion
of the capacity of a nuclear reactor.
It comes down to how much extra information
and computing power will save you
how much on the medical side.
What do the skeptics say?
Denis Hochstrasser: They say, with
some reason, that the greatest advance in
modern medicine was hand washing. Losing
would cutting down on alcohol and giving up
smoking. Not ITFoM. But the two are not
mutually exclusive. People do not see themselves
as they are. With a medical avatar that
evolves as a person gets older, they might.
Hans Lehrach: We are currently
per year, generating many more data than
Hans Lehrach
we did in the entire ten years of the genome
project. In my view, that information
than the 28% we have in clinical practice.
cine
now. It’s clear that our models initially
expect from ITFoM?
Hans Lehrach:
tualize drug development. For example,
pharma companies could take drugs
that have failed in clinical trials and get
patients that actually respond to them.
That would not just save costs and reduce
risks. It would also save time. Look, a drug
patent lasts 20 years. If you can cut the
time to development, which typically is 19
years, to 6 using this type of virtualization,
What does ITFoM mean for ordinary
humans?
Hans Lehrach: If you give people a
computer model of themselves that allows
them to test what will happen if they don’t
jog regularly and watch their diet, that’s
relevant to them. Empowering people to
have more control over themselves is a positive
development and potentially more
far-reaching than making classical medicine
more efficient.
example of you doing rounds at the hospital,
Denis Hochstrasser: Instead of me waiting
for the computer to download PDF files,
it shows me an image of the patient and
-
a toe infection. I go to each of these alerts,
the proper therapies with confidence
edge
and all the knowledge we have
-
Sounds useful.
Denis Hochstrasser:

GLOBAL INVESTOR 2.12 — 22
Misunderstanding
“Chronic diseases can’t
be prevented”
Effective public
health policy is key
to preventing
chronic diseases.
For example, many
countries have
introduced laws
and regulations
aimed at controlling
tobacco use by
taxing productions,
limiting sales to
minors and re -
st ricting smoking in
public spaces.
Photos: Stockbyte | Getty Images, Christian Schmidt | Corbis, Pia Tryde | Getty Images

GLOBAL INVESTOR 2.12 — 23
How do you get
people moving?
Change their
environment. In
2011, as part of an
effort to combat
obesity, the Los
Angeles County
Department of
Public Health
released a “Model
Design Manual for
Living Streets”
and invited every
city to use it.
Reality
According to the World Health Organization, 60%
of all deaths are due to chronic diseases, including
heart disease and diabetes. Their causes, or risk
factors, are known. Some risk factors, like age and
heredity, cannot be changed. But others, such as
unhealthy diet, lack of exercise and tobacco use,
can be. In fact, WHO reckons that eliminating
these ” risk factors could prevent 80%
of premature heart disease, strokes and type 2
diabetes, and 40% of cancers.

GLOBAL INVESTOR 2.12 — 24
Genome sequencing
The genomic doctor is in
The Human Genome Project’s success in classifying the
three billion “letters” comprising the human genome sequence
is one of the most impressive efforts ever in biomedicine.
Although a person’s genome can now be easily and relatively
inexpensively sequenced, the ability to interpret it has just
begun. Still, initial findings are already making an impact on
medical care.
Giselle Weiss, freelance writer
Eric D. Green, genomics researcher, has worked at the National Human Genome Research
he received Ph.D. and M.D. degrees from Washington University in Missouri, where he
was appointed in 1992 as an Assistant Professor of Pathology, Genetics and Internal Medicine.
Giselle Weiss: The Human Genome Project –
the massive international push to map
the genetic makeup of humans – concluded
in 2003. In hindsight, what was most
significant about it?
Eric Green: Two things. The obvious one
is to have produced the chemical blueprint
for the incredibly complicated system that is
the human body. That included developing a
catalog of the genes that make the proteins
that carry out everything we do, and also
providing fundamental information about the
code that gives out biological instructions in
other ways. That’s foundational. It’s forever.
It’s for all of humanity and it’s key.
And the less obvious one?
Eric Green: The Human Genome Project
changed the culture of biomedical research.
It did it in several ways, but most important
is that it created a much greater willingness
to share data and make it widely available
as fast as possible. It also revealed the
value of large teams of scientists working
together, rather than individually, in the pursuit
of audacious goals. These things continue
to have huge consequences for science
today.
What originally drove the project?
Eric Green: In the late 1980s, when all
this was just starting, the number of diseases
for which the specific genetic cause
was known numbered just a few dozen.
Yet we knew that there were thousands of
genetic diseases. The rationale for the
Human Genome Project was to open up
the genetic equivalent of a black box.
We wanted to get our hands on the information
we needed to figure out the changes
that cause devastating rare genetic diseases
like Huntington’s disease and that predispose
people to more common diseases like
hypertension and cardiovascular disease.
What are some of the earliest fruits
that genomics will deliver clinically?
Eric Green: I would lead with its effects
on cancer. Because what’s happening with
cancer is truly game-changing.
In what way?
Eric Green: Cancer is basically a disease
of the genome. It involves cells that have
had major genomic changes, aberrations
that cause the cells to grow out of control.
The tools that we have for sequencing
genomes now allow us to look at the genome
of any cancer and actually see what
derangements it contains. Those derangements
tell us why a cancer cell is a cancer
cell, why it behaves the way it behaves,
but more important, how it is broken.
Photo: Steffen Thalemann

GLOBAL INVESTOR 2.12 — 25
“The tools that we have for sequencing
genomes now allow us to look at the
genome of any cancer and actually see
what derangements it contains.”
Which enables you to do what?
Eric Green: Everybody has known for
some time that cancer is not one disease.
People with the same apparent type of
cancer can have very different outcomes.
If you look at those cancers under a microscope,
they look identical. But when you
look at their genomes, they can look completely
different. That information makes
it possible, say, to predict a good outcome
versus a bad one.
So we cannot yet say we have
better therapies?
Eric Green: In most cases, no, but at
least we have better ways of predicting
outcomes. Worldwide, there are dozens of
different cancer sequencing projects where
many tumors of a particular type of cancer
are being collected, sequenced and catalogued.
We think that in the next few years,
these efforts will change the face of
cancer diagnostics for some cancers, and
(fingers crossed!) maybe also provide better
insights for how to treat cancer.
It’s not just disease outcomes that are
different. People respond differently
to drugs too.
Eric Green: How people respond to
medication is also largely genetic. It has to
do with how we metabolize drugs and with
other things about how the drugs are acting.
And we’re learning how to predict that in
advance. There is the whole field of “pharmacogenomics”
that basically uses information
about an individual’s genome to determine
which medication they should get.
Pharmacogenomics is already standard care
for certain medications involved in the
treatment of AIDS, asthma and some types
of cardiovascular disease.
The cost of genome sequencing
has fallen dramatically. Why?
Eric Green: When the Human Genome
Project ended in April of 2003, our institute
published a paper describing a vision for
the future of genomics and calling for the
development of revolutionary new technologies
for sequencing DNA. In fact, we asked,
wouldn’t it be incredible if we could come
up with a technology that would allow us to
sequence a human genome for a thousand
dollars?
You had just sequenced the first
human genome for a billion dollars!
Eric Green: Which is why setting a goal
of sequencing a human genome for a
thousand dollars was, frankly, nothing short
of audacious. But we knew the cost had
to come down. We gave out millions of dollars
to all sorts of scientists, hoping that they’d
take risks and come up with some crazy new
ideas. The private sector saw this as a huge
opportunity as well, and poured in lots of
money. Good ideas emerged, they worked,
and what cost a billion dollars only ten years
ago is now down to just a few thousand.
What was the most surprising
finding about the human genome?
Eric Green: How few genes we have!
For a long time, we figured that, because
we are so complex and smart, the human
genome would have many more genes than
simpler organisms like fruit flies and worms.
But in fact, we have around 20,000 genes
(a few thousand more than a fruit fly
and roughly the same number as a mouse).
The other thing that’s been surprising is
that the majority of the functional parts of
our genome are not genes at all and do
not directly code for protein.
What do they do?
Eric Green: We are still learning about
those other functional parts. We know that
many of them act like dimmer switchers,
determining when and where and how
much a given gene gets turned on, how
much protein gets made and so forth. And
that’s where we probably get most of our
biological complexity.
Earlier you mentioned that, aside from
being able to predict response to this or that
drug or treatment, one day, hopefully,
we might even be able to make better drugs
based on genomic information. What
do we have to know to get to that point?
Eric Green: I think it’s unrealistic to think
about designing drugs just for us based
on our own unique genomic makeup. That’s
just not going to happen.
What will happen?
Eric Green: Genes act in complicated
networks of pathways where A affects B and
B affects C and C leads to D and so forth.
And through genomics – the name we give
to the discipline that studies the genome –
we are learning about what pathways are
altered in a given disease. And that immediately
gives insight about what existing
drugs or what newly developed drugs might
be useful for compensating for that alteration
in that pathway. So knowing which pathway
is altered can actually be more important
for developing therapies than just knowing
what individual gene is broken.
What has been the greatest
disappointment of the genome?
Eric Green: If there is a “disappointment,”
it is that we are recognizing just
how complicated the human genome is. It
has been a bit of a reality check. Because
it is not simply understanding the genes:
my grandchildren, and probably my
great-grandchildren, will still be interpreting
and reinterpreting the human genome
sequence. But it also means that the field
of genomics is going to be a hot one for

GLOBAL INVESTOR 2.12 — 26
The heart
factory
Providing high-quality medical care at an affordable cost is not just a challenge for rich countries.
In poor countries, the nominal cost of hospital treatment may be lower, but poverty puts it
well beyond the means of the vast majority of people. Indian heart surgeon and entrepreneur
Dr. Devi Shetty thinks that the solution lies in economies of scale.
Bernard Imhasly, journalist | Ryan Lobo, photographer

GLOBAL INVESTOR 2.12 — 27
Dr. Devi Shetty is a successful entrepreneur and healthcare innovator,
yet not too busy to do procedures in the OR, or to meet with patients.
Narayana Hrudayalaya provides 10% of all the heart operations in India.
As a young cardiologist in Kolkata, Dr. Devi Shetty treated Mother
Teresa. When he later moved to the state of Karnataka, in South
India, his father-in-law, a successful construction magnate, donated
money for a hospital. Its name – Narayana Hrudayalaya (“God’s compassionate
home”) – encapsulates Dr. Shetty’s vision: no person,
however poor, should be denied first-class treatment merely because
he or she cannot afford an operation. Today “NH,” in Bangalore, is a
franchise that includes hospitals in five other cities, making it the
largest provider of cardiac care in India. Close to 40% of operations
are performed on poor patients. NH’s low break-even costs (around
2,000 dollars) make it possible to apply surpluses from wealthier patients
to cover the costs of those who cannot pay. And because NH
does so many operations, quality is always improving.
Success has not dimmed Dr. Shetty’s devotion to medicine. He
still operates frequently and meets with patients. He wears blue scrubs
even in his office, a plastic cap tied around his head. On a day in
October he sits close to an elderly woman and explains her scans to
her, while a visiting journalist and a representative from McKinsey wait
their turn in another corner of the office.
“Respect.” Dr. Shetty uses the word twice in the space of a few
minutes after his patient – poor, barefoot and haggard-looking – has
left. “You have to respect the poor. They come to us after their heart
ailment has reached an advanced stage and their suffering has
become acute.” Rarely do they have insurance. Seven years ago,
Dr. Shetty launched an insurance scheme that now provides coverage
for over one million families in Karnataka at the cost of ten rupees per
person per month, or two dollars a year. Dr. Shetty uses the word
again: “You have to treat money with respect.”
Compassion and money are written in Dr. Shetty’s DNA. He was
born to a large family in India’s South Canara region, on the western
seaboard. His father died early of severe diabetes, leaving the nine
Shetty children in dire economic straits. But the Shettys hail from >
continued page 31

GLOBAL INVESTOR 2.12 — 28
“How much money can you throw
at the immensity of our social
problems? It will run out very soon.”
To help support Dr. Shetty’s low-cost healthcare coverage model, which gives millions of India’s
poor access to top-quality medical care, short nursing courses are given to patients’ family members
so that they can assist the skeleton staff in delivering post-operative nursing care.

GLOBAL INVESTOR 2.12 — 29

GLOBAL INVESTOR 2.12 — 30

GLOBAL INVESTOR 2.12 — 31
A patient recovers after surgery at one of Dr. Shetty’s hospitals. Despite handling 37 operations a day,
the NH franchise is still far from meeting demand. The group will expand to 14 hospitals by next year.
a business community that understands both the power of money as
a force for doing good and the reality of the bottom line. “Charity is
not scalable,” Dr. Shetty told the Indian daily “Economic Times” after
it recently voted him Entrepreneur of the Year.
Asked what that means, Dr. Shetty replies, “How much money can
you throw at the immensity of our social problems? It will run out very
soon.” Consequently, over time Dr. Shetty has recalibrated his business
model. Now, his is tightly focused on scaling up. “2.5 million Indians
need a heart operation,” he says. “Even with 37 operations a day, we
merely scratch the surface of the problem. We need to expand.” A year
from now, there will be 14 hospitals, all committed to the same goals.
They will replicate the model of Health City, a complex that has sprung
up just behind the original NH in Bangalore, offering a variety of medical
specialties to the poor at low cost through economies of scale.
“We perform 10% of all the heart operations in India,” says Viren
Shetty, Dr. Shetty’s eldest son and an administrator for NH. “Thus,
we can pool resources like blood banks and lab testing. It also gives
us bargaining power. We can buy consumables like sutures as well
as expensive MRI (magnetic resonance imaging) machines at very
competitive rates.”
Another of Dr. Shetty’s healthcare innovations is social: his hospital
in Mysore provides facilities for family members to stay with
patients and support the skeleton staff in delivering post-operative
nursing care. They are given a short nursing course. Even patients
get involved so they can become their own nurse once they are home
again. “We hope to make this a model for India,” says Dr. Shetty, “and
elsewhere as well.” Indeed, his high-quality, low-cost model has attracted
interest far beyond his homeland.
Viren Shetty pulls out his iPhone and points to a text message that
has just come in. It shows the previous day’s income and expenditure
for one of the NH hospitals, as well as the operating cash flow figures
derived from it. Each of the NH hospitals is treated as a profit center
and must generate an outline balance sheet – every day. Dr. Shetty
explains: “A balance sheet every month is like a postmortem report.
But a daily summary is a diagnosis. It helps us to get healthy hospital

GLOBAL INVESTOR 2.12 — 32
Mobile phones and telemedicine
eHealth for all
The developing world has adopted mobile telephony at astonishing
rates, with population and geographic coverage nearing 90%,
even in Africa. The technology is proving an invaluable tool
for sharing health information and gathering data from remote
and underserved regions. But “eHealth” solutions are only as
good as the institutions that support them.
Giselle Weiss, freelance writer
Listen to this article on Global Investor’s Knowledge Platform:
www.credit-suisse.com/globalinvestor
S. Yunkap Kwankam, CEO, Global eHealth Consultants and Executive Director, International
Society for Telemedicine and eHealth, Geneva. Born in Cameroon, he earned his PhD in
electrical engineering from North eastern University. He worked in the USA before becoming
Professor and Director at the Center for Health Technology at the University of Yaoundé.
He was Coordinator of eHealth at the WHO in Geneva for four years.
Giselle Weiss: Information and communications
technology (ICT) has pretty much
transformed the world as we know it. But it
has not transformed healthcare. Why?
S. Yunkap Kwankam: It actually has
transformed healthcare. Perhaps not to the
extent that it has transformed other aspects
of life. In the day-to-day, you cannot go
anywhere without running into IT-enabled
systems. Whereas in health, as a patient, it
is not very obvious to you what ICT systems
are behind the services you’re receiving.
But health workers see the transformations
that have occurred in the health system
thanks to ICT. In fact, we say that ICT is the
third pillar of the health industry.
What are the first two?
S. Yunkap Kwankam: Chemistry, which
in the 19th century launched what would
become the pharmaceuticals industry, and
physics, which in the last century gave
us imaging systems and equipment. ICT is
the foundation of the knowledge-based
health systems of the 21st century. It really
has had a profound impact.
You talk about mobile phones as an
enabling technology for healthcare
in the developing world.
S. Yunkap Kwankam: Close to 5.9 billion
of the world’s people have access to a
cell phone. In Africa, both population and
geographic coverage reach around 90%.
It’s the technology of choice.
For what?
S. Yunkap Kwankam: Patients reaching
health workers, or health workers communicating
among themselves, for one. Just
the communication aspect is an area of
significant impact. Roads and other forms
of infrastructure are so poor that communication
assumes even greater importance.
Can you give me a specific example?
S. Yunkap Kwankam: One of the
applications that is being used currently is
rapid SMS. It allows you to send and
receive data between a cell phone and a
computerized database. For example, in
Bonsaaso, in the Amansie-West District of
Ghana, the Millennium Villages Project
uses a rapid SMS application called Child-
Count+. Mothers enter and send data
relating to their children’s health to project
staff, who record and manage it. This site
also has a telemedicine consultation center
to deliver health services beyond the
physical reach of the healthcare provider.
How does that work?
S. Yunkap Kwankam: In this case,
community health workers in the Bonsaaso
Photo: Cédric Widmer

GLOBAL INVESTOR 2.12 — 33
cluster of villages go around the community
and attend to patients. If they encounter a
problem that they are unable to solve, they
call a nurse or a midwife, or eventually a
doctor for advice about what to do.
How do mothers find out
about these things?
S. Yunkap Kwankam: With SMS you can
broadcast a message to every subscriber
on your network. For example, the MAMA
project (Mobile Alliance for Maternal
Action) provides free health messages to
new and expectant mothers around the
world. Mothers register for the service by
indicating the expected due date or the
birthday of their infant.
But communication is just one
of theadvantages you mentioned.
S. Yunkap Kwankam: Yes, the other is
capturing and analyzing good data to make
informed decisions. An example of that is
SMS for Life, which was trialed in Tanzania
using text messages and electronic
mapping technology to solve a problem
of stockouts of antimalarial drugs.
Before that, central planners did not
know what medicines were available
in what centers.
Cell phones for health!
S. Yunkap Kwankam: Yes and no. The
World Health Organization (WHO) Commission
on Social Determinants of Health
has pointed out clearly that you cannot just
focus on improving the health system.
If you look at what produces health, it is
water and sanitation, food and nutrition,
housing and education. In actual fact, you
have to fix entire economies. You have to
fix governance. You have to fix agriculture.
You have to fix communications.
The major problem faced in many
developing countries used to be that
of communicable diseases.
S. Yunkap Kwankam: That was then.
Now, as life expectancy increases, chronic
diseases are beginning to make up a
greater share of the disease burden. Moreover,
there are huge shortages of health
workers. A WHO report published in 2006
listed 53 countries worldwide where the
number of doctors, midwives, nurses and
pharmacists, per capita, was insufficient
to provide basic services. Thirty-three of
those countries were in sub-Saharan Africa.
Which implies what, in terms of ICT?
S. Yunkap Kwankam: We have to
explore what ICT can do for these other
pathways to good health. We have to shift
the emphasis from ICT for health to ICT
“We have to shift the emphasis from ICT
for health to ICT for development because
many of the challenges that these countries
face are really problems in development,
and not just health alone.”
for development because many of the
challenges that these countries face are
really problems in development and not just
health alone. Another compelling reason
for the shift is that many of the decisions
about investing in infrastructure for ICT in a
country are out of the purview of a health
minister. But health considerations need to
be part of the thinking when that infrastructure
is being put in place.
In the West, we take infrastructure
for granted.
S. Yunkap Kwankam: When I talk about
telemedicine, I always cite the example
of Medgate, out of Basel. Medgate is very
successful. The service currently handles
around four thousand or five thousand
patients a day: people call in either by
phone or the Internet. Statistics show that
half of the people who call in get the
problems resolved. And that’s terrific! But
behind the simple technology of using
a cell phone to call a doctor in the Medgate
center lies a lot of infrastructure, including
payer systems (i.e. insurance schemes),
electronic prescribing and a stable supply
of electricity. In an African country, there
is no guarantee. The infrastructure adds a
layer of complexity to the problem.
Setting aside for a moment the broader
issue of development, what are
some of the limitations of ICT itself?
S. Yunkap Kwankam: One of the biggest
limitations that the technology faces
has to do with legal and regulatory issues.
When you carry out an intervention that
spans several jurisdictions – or countries –
knowing which laws to apply and who has
responsibility can be quite murky. The
regulatory environment has not kept pace
with the advances in technology. Digital
signatures are a case in point. In the end,
you need a paper signature to validate
the electronics. It’s a real bottleneck. So
is interoperability of systems. Cyber abuse
is another obvious problem.
You have constructed a list of six eHealth
“grand challenges” (see box). Could
you share one or two of them with us?
S. Yunkap Kwankam: One is what I call
going to scale. In other words, ICT interventions
have to be commensurate with the
size of the problem. Another is to anticipate
where the health system is going, and use
technology to stay ahead of the game.
The power of ICT is staggering if you think
of it in terms of people, processes and
technology. Leveraging that power can do
Six eHealth
grand challenges
1. Creating a “knowledge commons” for
eHealth, a widely available repository
of information on eHealth that is global
in scope.
2. Scaling up eHealth interventions,
based on evidence, to a size
commensurate with the magnitude of
the problems to be addressed.
3. Creating integrated eHealth systems
to resolve the perennial issues of siloed
systems and lack of interoperability.
4. Transforming health workers into
ePracti tioners and building individual
and institutional capacity to use
eHealth tools and services.
5. Developing information and
communications technology (ICT) for
health by viewing health as a production
function, and investigating where
ICT can support it.
6. Building ICT for the health system
of the future by anticipating future
needs, thereby reducing the time lag
intervention to seeing the impact.
Source: S. Y. Kwankam, “Bulletin of the World Health
Organization,” vol. 90, 2012, pp. 395–397.

I/8
II/13
IV/40
V/47
Beyond pills III
Getting things right
Anyone who has ever forgotten something at the grocery store
because they left their shopping list at home can understand
the simple brilliance in making a list. But when Harvard surgeon
Atul Gawande suggested making a surgical checklist to his
colleagues, some 20% balked. Gawande persisted and codified the
benefits of doing so in his bestseller “The Checklist Manifesto:
How to Get Things Right” (2009). Independent studies of the
effect of surgical checklists show that they can reduce mortality
rates by one-third – if everything on the list is followed.
Atul Gawande
Photo: Alyson Aliano, Redux, Redux, laif

GLOBAL INVESTOR 2.12 — 35
Paying for healthcare
Japanese
lessons
Just who pays for healthcare, and how much, depends on varying views of what
constitutes “appropriate” treatment, the amount of income that providers
expect to earn and patients’ expectations of healthcare. Consequently, healthcare
expenditures have a built-in (albeit unsustainable) mechanism for escalation.
Japan’s single-payment system provides one approach to containing costs.
Naoki Ikegami, health economist, Keio University, Tokyo
There are several key issues in paying for healthcare. The first is: what
constitutes “appropriate treatment”? Patients tend to think that this
is a black-and-white issue. In other words, for any given condition,
there is only one course of treatment that is the most appropriate.
However, most healthcare falls in a gray area referred to by physicians
as “it depends” (on the patient). What they do not say is that it also
depends on the resources available, their personal inclinations based
on where they have been trained and how they are paid. If their income
is linked to their activities, the white “appropriate” area will expand.
On the other hand, if income and activities are not linked, this area
will contract, and there will be waiting lists of patients who have
conditions not needing immediate treatment.
The second issue is that healthcare expenditures for the patient,
insurance plans and government represent income for physicians and
hospitals. Personnel costs in high-income countries are typically about
half of the total. So when healthcare providers talk of “costs,” they are
really talking about their income. Should physicians earn about the
same as the average worker or ten times more? How much should they
earn relative to nurses? In many middle-income countries, and among
some specialties in the USA, physicians earn ten times more than
nurses. Limiting delivery to specialists and limiting entry only to those
well trained are said to be prerequisites for maintaining quality. >
Sometimes
appropriate
Physician
Always inappropriate
Always appropriate
Always inappropriate
Patient
01_What is “appropriate” treatment ?
Patients frequently see appropriate healthcare interventions as a
black-and-white issue, whereas for physicians, the question of whether
or not to treat falls into a gray area. Source: N. Ikegami

GLOBAL INVESTOR 2.12 — 36
care
will become a greater
issue in Japan despite
the fact that its health
expenditures have been
relatively well contained.”
For example, in France, only neurologists can diagnose Alzheimer’s
disease and start prescribing targeted drugs. But these restrictions
also reward physicians in some specialties with high incomes.
The third issue is the patient’s expectations of healthcare. The
wonders of healthcare are widely publicized by the media. Accordingly,
in a life-or-death situation, most patients are likely to grasp
at straws, no matter how low the probability of recovery is, or how
much it costs. Many are prepared to sell all their assets and incur
heavy debt if services are not made available by the government. A
low-income earner may be resigned to a low level of housing, but not
to a low level of healthcare. Such being the public sentiment, it is
difficult for any elected politician, except, perhaps, in the USA, to
explicitly state that a patient with low income is not entitled to the
same quality of healthcare as a patient with high income.
No way but up
02_Containing healthcare costs by means
of a single-payment system
Annual changes in Japan’s GDP, medical expenditures and fee schedule
global revision rate, 1980 – 2010. Source: “Health Affairs,” May 2012, p. 1052
%
10
8
6
4
2
0
–2
–4
–6
–8
1980 1985 1990 1995 2000 2005 2010
Gross domestic product (nominal)
Fee schedule global revision rate
Medical expenditures (nominal)
Given that this is the nature of healthcare, it comes as no surprise that
healthcare expenditures have a built-in mechanism for escalating.
Based on past trends, in 2000 the US Centers for Medicare and
Medicaid Services estimated that the health expenditures share of the
GDP would be 38% in 2075. However, in other high-income countries,
such levels of expenditures cannot be even contemplated. The basic
reason is simple: government must contain total healthcare expenditures
because there is a limit to which those with high income and
good health are willing, or more correctly coerced, to pay for the care
of those with low income and chronic illness.
At a more practical level, healthcare competes with other public
services in the annual budget allocation process. This is true whether
health expenditures are primarily funded by taxes, as in the UK and
Nordic countries, or by social insurance premiums as is the case in
Germany and France. The reason it also applies to the latter is because
revenue from premiums must be supplemented by taxes in order to
keep labor costs at an internationally competitive level (typically, half
of the premiums are paid by employers). Thus, how much could be
Incidentally, making patients pay more does not have much impact
because of the 80:20 rule in health expenditures. That is, 80% of the
total expenditures are spent by 20% of the patients with high costs.
portion
paid by patients with high costs must be increased. However,
forcing them to pay such high amounts would negate the rationale for
governments to finance healthcare.
How, then, can health expenditures be contained? The problem of
containment is not related to how the healthcare system is structured.
For example, Japan’s system has many features that are similar to that
of the USA: over 3,000 health insurance plans, and a delivery system
that is dominated by the private sector. Nor does the government
impose a tight global budget. Providers are basically free to invest and
deliver any service that they think is needed by their patients. As a
consequence, waiting lists are not a social issue. But, as a share of
the GDP, Japan’s health expenditures are only 8.5%, compared with
16.4% in the USA. This difference can mainly be explained by the fact
that virtually all prices and conditions for billing are set by the Japanese
government (see Figure 2).
A single fee schedule key to controlling costs
In the biennial revision of prices, the prime minister first decides on a
so-called global price revision rate based on his evaluation of the
political and economic situation. Next, the price of each item is revised

GLOBAL INVESTOR 2.12 — 37
Photo: Benjamin Parks
individually by the health ministry based on policy priorities, negotiations
and surveys. For example, in the 2002 revision, the global rate
was reduced by 2%, but the price of taking an MRI (magnetic resonance
image) of the head was reduced by 30% because the number
of MRI examinations had increased “inappropriately.” On the other hand,
in the 2008 revision, prices in emergency care and obstetrics were
increased because the government had to respond to media reports
of deficiencies in these areas. Drug prices are generally revised more
objectively, based primarily on the result of a market price survey. The
selling price is typically lower than the price set by the government
because of competition among distributors. Once the actual market
prices have been determined, the revised price is set so that it is only
2% higher than its volume-weighted average market price. These
revisions have resulted in a downward spiral of drug prices.
Revisions of the global rate are reflected in the annual growth
rate of health expenditures. However, expenditures also increase by
non-price factors: advances in technology and demographic factors,
which together have led to annual increase rates of 2% to 3%. An
example of the former is the transfer in “appropriate” imaging equipment
from a simple X-ray to a CAT (computer-assisted tomography)
scan to an MRI, and now to a PET (positron emission tomography)
scan. Until the 1980s, demographic factors used to consist mainly of
increases in population, but since then, the most influential factor
has been the aging of society. The percentage of the population aged
65 and over has been increasing at the rate of 1% every two years;
the current proportion is 23%, making Japan the oldest country in
the world. Incidentally, nominal increases in GDP are more important
than real (GDP-deflated) increases because the price of health services
tends to be determined relatively independently of the consumer
price index.
When the economy was growing at the rate of 5%, as it did in the
1980s, the ratio of health expenditures to GDP remained constant
because small increases in the global rate and increases due to nonprice
factors could be absorbed. But since the 1990s, the economy
has stagnated, and as a result, the share of health expenditures has
increased. Meanwhile, the national debt, already twice GDP, continues
to increase. How to finance healthcare will become a greater issue
in Japan despite the fact that its health expenditures have been relatively
well contained. In order to meet this challenge, the government
must negotiate with provider organizations so that the services delivered
and the income levels of healthcare professionals can be made
Naoki Ikegami is Professor and Chair of
the Health Policy and Management
Department at Keio University School
of Medicine. He has served as a consultant
to the World Health Organization and
the World Bank. He is currently President
of the Japan Health Economics Association
and is past President of the Japan Society
for Healthcare Administration. He is
also a Senior Fellow at the University of
Pennsylvania’s Wharton School.

GLOBAL INVESTOR 2.12 — 38
Low-cost medical technology
Do-it-yourself
tools for health
The lack of appropriate medical technologies in resource-poor
areas has spurred device “hackers” to create construction
sets for medical equipment that healthcare users and providers
can assemble themselves. This doesn’t just solve an immediate
equipment problem. It also encourages invention.
José Gómez-Márquez, medical device designer, Little Devices Lab, Massachusetts Institute of Technology
Listen to this article on Global Investor’s Knowledge Platform:
www.credit-suisse.com/globalinvestor
Modular, color-coded parts made of rugged materials allow medical professionals in resource-poor settings to design
medical technologies that may be better suited to the particular challenges of their environment than high-tech devices.
In a Nicaraguan coffee village, Mauro Perez,
father of a one-year-old, learned to make a
nebulizer that would later nurse his daughter
out of a month-long pneumonia crisis. His
shopping list at the hardware store? Tubing,
an aerosolizing cup, a bicycle pump and a
paper filter. Two hours away, nurse Danelia
Urbina uses a do-it-yourself (DIY) stethoscope
attachment made out of overhead
transparency slides to transmit heart sounds.
In Ethiopia, a team of engineers at Addis
Ababa Institute of Technology took discarded
television components and used them to
create a device that measures oxygen in the
blood called a pulse oximeter. This is the world
of DIY medical technology, an emerging field
in low-fi medical equipment in emerging
markets. Motivated by enabling technologies,
a growing number of users are venturing
beyond their role as patients and healthcare
providers to become inventors. For healthcare
in the developing world, invention still
matters.
An article in the August 2012 issue of the
prestigious medical journal “Lancet” reports
that 80% of all medical devices in developing
countries are provided through donations.
Only about 40% of these actually function.
Many are dead on arrival, having been designed
to operate not in rugged environments,
but instead in hospitals in OECD countries
with ample replacement parts, reliable training
and solid infrastructure. In clinics found
in resource-poor settings, these particular
design criteria are irrelevant.
Our lab at the Massachusetts Institute of
Technology designs devices aimed at emerging
markets using a strategy centered on
user empowerment. Our partners in developing
countries are our co-designers, not just
our customers. Rather than wait for the health
system to mature and catch up with modern
medical technology, we push the technology
to adapt to the system as it stands. When
your patients are at stake, you don’t wait for
the highway to be built – you design the medical
device equivalent of a Land Rover.
In this setting, selecting the right design
criteria is key. It involves much more than
equipping a device with solar panels, and waterproofing
and ruggedizing it. For example,
in low-income countries, scarcity drives the
reuse of devices that should not be reused,
like needle syringes. Here, a smart design
specification is to force disposability of the
instrument (auto-disable syringes).Wireless
data transfer enables performance tracking
and alerting of remotely located surgical
sterilizers, medicine coolers and neonatal in-
Photos: Jeff Harris | David Carmack

GLOBAL INVESTOR 2.12 — 39
cubators. Finally, taking advantage of locally
available parts to produce medical equipment
helps to lower production costs and increase
fabrication know-how, which in turn promotes
adoption of technology.
Design strategies
Once the design criteria have been established,
the key is to figure out how to achieve
them. This process of invention and design
can be kick-started using a series of strategies.
For instance, hybridization is a mash-up
of two very different objects that transforms
them into more than the sum of their parts.
Cell phone microscopes, such as those from
MIT’s Camera Culture group, are a good illustration.
At its most basic, the device is a
lens on a camera connected to a walkietalkie.
The long-run potential of such combinations
is a network of devices armed with
image recognition algorithms that can share
information and predict disease: the end result
is an early warning system you can store
in your pocket.
Another strategy is the combination of
vintage technologies with modern applications.
What we call “improvisation hunting”
seeks inspiration in the daily efforts of people
in developing country settings to cobble
together their own medical solutions. One
example is the origami asthma spacer designed
at Stanford University in California
after researchers noticed that physicians in
Latin America used cut-up Coca-Cola bottles
to serve as inhaler spacers. This is a 50-cent
innovation for a disease that affects 40 million
Latin American patients.
Once we have decided on a design strategy,
we begin the process of rapid prototyping
through trials in the field. A month in front
of potential users in real-world settings is
worth more than a year in a lab full of whitecoated
engineers. This approach produced
technologies such as our Solarclave (a solarpowered
device for sterilizing surgical tools),
microfluidic (lab-on-a-chip) technologies for
diagnosing diseases and environmental conditions,
low-cost prosthetics, and a DIY device
toolkit.
Arbitraging the supply chain
In the developing world, being locally available
need not mean bamboo and “natural” materials.
Toys have emerged as part of a vast global
supply chain that offers opportunities for
dual-use engineering. For example, the ratchet
mechanism in a toy helicopter can double
as trigger mechanism for a dry powder inhaler.
Electronics inside a talking doll can be
José Gómez-Márquez was born and raised in Honduras. He directs the Little Devices Lab
at the Massachusetts Institute of Technology (MIT) and teaches D-Lab: Health, a course on
designing global health technologies. He is a three-time MIT IDEAS Competition winner,
including two Lemelson Awards for International Technology. In 2009, he was selected for
“Technology Review” magazine’s list of young innovators under 35 (T35), which also named
him Humanitarian of the Year.
repurposed to prototype an alarm for an intensive
care unit. The tight manufacturing
tolerances of Lego bricks lend themselves to
precision diagnostics for modular lab-on-achip
applications.
Helping to foster ingenuity
Construction sets like those of our MEDIKit
Project, now part of LDTC+Labs LLC, consist
of building blocks – traditional devices transformed
into modular, color-coded parts – that
empower doctors and nurses in developing
countries to invent their own medical technologies.
The kits span six areas of medical
technology: drug delivery, paper diagnostics,
microfluidics, prosthetics, vital signs and surgical
instrumentation. The kits show users
how the devices work, enabling them to rearrange
the different component parts to create
a variety of unique devices.
Medical technologies for developing countries
must be affordable and contextually
appropriate. With the right combination of
research and development investment, they
can be profitable. The combination of growing
government health expenses, persistent lack
of infrastructure, and rapid advances in enabling
technologies (rapid prototyping, mobile
telephony, programmable electronics) is
opening the door for many devices to have
an impact on health systems. There is a
strong case for investing in the research and
development and commercialization stages
of the sector. There is also growing evidence
that these technologies can trickle up to developed
world markets. Adherio, a technology
we created for ensuring that Pakistani
patients with tuberculosis follow through on
their medication, is now being transferred to
the USA, where lack of patient compliance
costs an estimated USD 290 billion a year.
Distributed (i.e. non-centralized) and “pop-up”
labs in developing world hospitals are becoming
an attractive option for expensive institutional
research and development centers
with high overheads.
The future is bright for DIY medical technology
thanks to enabling technologies,
global networks of everyday innovators and
the promise of helping scores of patients who
With special thanks to Anna Young of Little Devices Lab
for analysis and research.

I/8
II/13
III/34
V/47
Beyond pills IV
Mobile mental health
The World Health Organization estimates that some 450 million
people worldwide suffer from mental disorders. Moreover,
social stigma and a lack of psychiatrists hinder treatment. In India,
where there is one licensed psychiatrist for every 400,000 people
(the USA has 58 per 400,000), a roving RV is changing that.
The Chennai-based Schizophrenia Research Foundation (SCARF),
which despite its name covers a range of mental health issues,
now reaches 800 villages, connecting rural patients with generally
urban-based psychiatrists via teleconferencing. Demand is high,
leaving each patient with only 20 minutes for a consult.
Schizophrenia Research Foundation
Photo: Schizophrenia Research Foundation, India

GLOBAL INVESTOR 2.12 — 41
Mental health in India
The neglected
cousin
In India, longer lifetimes, growing rural-urban migration, smaller families and rapid economic
change all represent stress factors that pose an increasing challenge to mental health with
consequences that are both personal and far-reaching. Although policy makers agree on a broad
strategy for addressing the problem, previous inattention to it and a lack of human resources
mean that implementation will not be easy.
Ajay Mahal, health economist, Monash University, Australia, and Victoria Fan, research fellow, Center for Global Development, Washington, D. C.
According to a recent study in the medical journal “Lancet,” nearly
187,000 suicides occur in India annually. Suicides, particularly among
rural Indian households, have attracted much attention as an unintended
side effect of the Indian growth story and are often linked to loss of
livelihood and indebtedness. Less well appreciated is the broader
public health challenge of mental illness, an important underlying risk
factor for such deaths. In fact, excessive attention to mortality may
have detracted attention from morbidity – departures from a state of
good health and normal functioning – where the impact of mental
illness is mostly felt. Available data suggest that impaired cognitive
7.5% and
11% of Indians aged 60 years and over. But dementia isn’t the only
problem in this sector of the population. In some parts of the country
depression among the elderly has reached rates in excess of 50%.
An illness burden second only to cardiovascular disease
Among younger adults, various types of “mood disorders,” including
depression, are common. Rapid increases in alcohol sales and household-level
studies showing high frequency of alcohol consumption on
a daily basis suggest that alcohol dependence is on the rise. Children
Research found that nearly 13% of children below 15 years of age
suffer from mental retardation and behavioral problems. Recent efforts
to collect nationally representative information on the state of mental
health in India’s population have been marred by controversy, but
there is little disagreement among mental health experts about its
growing significance. The World Health Organization estimates that
mental health conditions account for around 10% of India’s burden of
ill health and death, second only to cardiovascular disease among
non-communicable conditions.
Health outcomes are not the only casualty of mental illness. Research
for developed countries also points to serious adverse economic
consequences. One recent study for Europe concluded that
mental health problems would cost every European household roughly
USD 2,800 in costs of treatment and productivity losses. Similar
data are unavailable for India, but three factors suggest that economic
outcomes of mental illness in India could be comparatively
worse. First, either many people with mental illness belong to the
most economically productive age-groups, or these disorders occur
among children, with implications for the future quality of the labor
force. Second, stigma attached to mental illness and smaller family
are also at risk. One 1990s study of the Indian Council for Medical sizes increase the risk that the emotional and economic burden of >

GLOBAL INVESTOR 2.12 — 42
“Existing third-party public
and private insurance
plans in India do not cover
expenses for care related
to mental health, so
an estimated 79 % of the
total cost is paid for out
of pocket.”
Victoria Fan joined the Center for Global
Development after completing her doctorate
at the Harvard School of Public Health,
where she wrote her dissertation on health
systems in India. She has worked at
various non-governmental organizations in
Asia and has served as a consultant
for the World Bank and the World Health
Organization.
any caregiving will be borne mostly by a small number of close family
members. Finally, data from a nationally representative household
survey point to a significant financial burden on households, because
only about 45% of hospital stays and 20% of outpatient visits related
to psychiatric care occur in subsidized public sector health services;
the remainder occur in the private sector. We have found that existing
third-party public and private insurance plans in India do not cover
expenses for care related to mental health, so an estimated 79% of
the total cost is paid for out of pocket. There are additional implications
for economic inequality. Poorer households are at greater risk
for mental illness relative to their economically better-off counterparts,
but multiple studies also show that mental illness is associated with
inferior economic outcomes.
Rapid change entails factors that undermine mental health
Mental illnesses will remain a prominent feature of India’s public health
landscape for the foreseeable future. The number of people aged
6093 million
at present to more than 323 million by 2050. Consequently, Alzheimer’s
disease and other forms of dementia are likely to be observed with
greater frequency. Women in India are also beginning to live longer
than men, just as in the more advanced economies. This trend has
implications for their mental health in old age, as single elderly
people tend to experience much higher rates of depression according
to multiple studies in India and elsewhere. Moreover, physical ill
health – particularly conditions such as heart disease, diabetes and
cancer – and depression tend to occur together. South Asian populations
are known to be at especially high risk for cardiovascular disease
and diabetes, so their mental health will remain an object of concern.
Broader social forces are also at play. Growing rural-urban migration,
smaller families, rapid economic change and a lack of social safety
nets will expose large numbers of Indian households to a variety of
factors that undermine mental health, including loneliness, economic
uncertainty and a lack of support systems in caring for the elderly
and young children. And India faces long-standing problems of poor
physical maternal health that, in turn, is linked to inferior child health
outcomes and greater risks of mental retardation. While not all mental
disorders are treatable, a number of treatments and prevention

GLOBAL INVESTOR 2.12 — 43
Photos: Steffen Thalemann | Anthony Jeong
practices have been assessed to be effective in low-income settings
such as India’s. These include counseling and psychotherapy (e.g.,
for depression and other behavioral disorders) and pharmaceutical
interventions (e.g., for schizophrenia, dementia and depression).
Evidence, mostly from developed countries, suggests that various
forms of community and family support along with provision of drugs
can also address behavioral problems associated with mental illness
among children. Better population and healthcare provider awareness
of mental illness at the primary care level can help identify cases and
allow timely interventions. Provision of coordinated health services
for mental health and physical health at the primary care stage is
also desirable given the co-occurrence of both sets of conditions in
many patients. Mental health experts largely agree that managing
patients at the level of the community, including ambulatory care
received at primary health centers, is likely to yield high returns in
terms of health gains relative to cost.
Resource constraints complicate the way forward
India lags in the effective implementation of many of these interventions,
in part because mental health has remained a neglected cousin
of the government’s health policy agenda. Available estimates suggest
that mental health attracts no more than 2% of India’s government
health expenditures, considerably less than the health burden it imposes
on the population. Despite the National Mental Health Programme
and a commitment to a community-based mental healthcare
model that dates to 1982, even this limited spending favored hospitalbased
spending. No doubt hospital-based specialized care can contribute
to treating patients with severe mental health conditions. However,
there is a cost to doing so. Hospital-based care isolates patients
and does little to end the stigma attached to mental health. It is also
diffi cult to access, since hospitals tend to be located in urban areas.
A natural solution lies in better integrating mental services at the
primary care level with hospital services, so that only the severe
cases are referred to hospitals. A limited supply of psychiatrists and
healthcare providers with training in mental health, however, adds
an additional layer of difficulty when considering options to expand
community-based mental health services to rural areas. This shortage
is compounded by a reticence on the part of Indian governments to
engage with a rapidly growing private sector, which also happens to
dominate the provision of ambulatory care services as well as “alternative”
or “traditional” therapies. Additional inertia results from healthcare
provision being primarily a responsibility of provincial governments
that tend to be resource-constrained.
India’s policy makers are beginning to recognize the challenge
posed by mental health. For close to two decades, the central government
has left the centerpiece of its community-based approach – the
District Mental Health Programme – essentially adrift. India’s central
Ministry of Health is planning to support a renewed exercise to scale
up this program to cover all districts in the country over the next five
years. A mental health policy group, comprising many experts from
outside the government, is helping to shape this new exercise, after
close consultation with civil society organizations and local and provincial
governments. However, implementation remains a challenge.
And the new strategy offers little in the way of addressing major human
resource shortages, or engaging the private sector. By way of comparison,
one could argue that there is a paradox in which wealthy countries
face a large burden of mental illness despite their wealth. Consequently,
even in such materially developed countries, new approaches and ideas
Ajay Mahal is the Finkel Chair of Global Health
at Monash University. He received his
M.A. from the University of Delhi (1986) and
his Ph.D. from Columbia University (1995).
Until August 2010, he was Associate
Professor at the Harvard School of Public
Health and before that a senior researcher at
the National Council of Applied Economic
Research in New Delhi.

GLOBAL INVESTOR 2.12 — 44
Social entrepreneurship
Getting
back to work
Returning to work after a long illness can be difficult. In particular,
people with a history of mental illness face workplace hurdles
that may seem insurmountable. Deborah Wan Lai Yau describes
how helping these patients to reintegrate through social
entrepreneurship benefits everyone involved.
Deborah Wan Lai Yau, President, World Federation of Mental Health
Listen to this article on Global Investor’s Knowledge Platform:
www.credit-suisse.com/globalinvestor
Deborah Wan Lai Yau has devoted her career as a social worker to assisting patients who are
social entrepreneurship concept to Hong Kong as early as 1994. In 2008, she was recognized
with the Outstanding Women Entrepreneurs Award, conferred by the Hong Kong Women
Professionals and Entrepreneurs Association.
I have always had enormous respect for
patients recovering from mental illness for
their ability and willingness to return to work.
Given training opportunities, they perform as
well as people without mental illness, and
are also able to maintain a healthy lifestyle
and mentally stable outlook. Our society often
fails to appreciate that people recovering from
mental illness represent social capital, and
thus tends to view them negatively. At the
time, I was CEO of a Hong Kong non-profit
organization focusing on mental health – the
New Life Psychiatric Rehabilitation Association.
Consequently, I devoted myself to
giving a new lease on life to people who have
suffered episodes of mental illness.
In the 1980s, my team and I concentrated
on developing community psychiatric rehabilitation
services, mainly residential care and
vocational rehabilitation, such as sheltered
workshops. Once these services were well
developed, we realized that many residents
and sheltered workers were not able to take
the next step owing to a lack of confidence
in facing the public, and stress related to
adjusting once again to work.
So, I organized a pilot project to set up a
daily market stall in the community for selling
Photo: Grischa Rüschendorf

GLOBAL INVESTOR 2.12 — 45
“My ultimate aim is to encourage
small businesses.”
fresh vegetables. These came from a sheltered
farm workshop that was founded in
1994 for about 160 workers with psychiatric
disabilities. We called it “simulated business”
because it was intended to resemble as
closely as possible a real work situation in
which persons with psychiatric disabilities
could interact with regular customers. We
provided a job coach to help the former patients
to be salespeople. The project was well
received by both neighboring stall owners and
customers. This successful effort led to us
setting up convenience stores in hospitals
from 1997. Three years earlier, we secured a
public cleaning contract in parks and the city’s
indoor games hall and in 1999 also the first
licensed restaurant in the games hall. These
projects won numerous awards for best practices
in reintegration. After witnessing the
impressive results of providing training and
employment opportunities for persons with
psychiatric disabilities in these projects, the
government subsequently set up a fund to
provide seed money to social enterprises.
Balancing objectives the key to success
Social enterprise has two main objectives.
One, obviously, is social, and in my own experience,
it consists in training and employment
opportunities for persons with a history
of mental illness. The other objective is to
sustain a business with profits generated and
to use the surplus to create other new social
enterprises or to expand the existing one. The
directors of this limited company do not share
in the profits. Balancing social and business
objectives is more difficult than running a
business with profit sharing, as the two objectives
are entirely different. Sometimes, the
managers focused more on the social objective,
and the enterprise failed to produce
sufficient income (neither the directors nor
the managers were former patients). It is
the combination of both types of expertise –
understanding the social objective and marketing
savvy – that makes it a success. I was
fortunate to have recruited a team of marketing
staff to assist me in running the businesses,
and a team of dedicated social workers
to deliver on the social objective.
In response to the growing awareness of
healthy food after the 2003 SARS (severe
acute respiratory syndrome) epidemic, in 2004
I began to set up healthy-living specialty
organic shops that sold organic veggies (again
from the sheltered organic farm) in the railway
concourse, followed by four more shops later.
As of 2009, we had established a total of
20 social enterprises, providing more than
230 jobs for persons with psychiatric disabi l-
ities, the disadvantaged and the able-bodied,
and simultaneously creating over 450 training
positions with a total turnover of over HKD 25
million that yielded a small profit.
A model that others are following
Responding to the success of social enterprises
in Hong Kong, our mainland China
counterparts made numerous study visits to
Hong Kong to learn about this approach to
the disadvantaged. I am glad to say that
Guangzhou City also set up a farm to provide
both employment and training opportunities
to persons with psychiatric disabilities, and
a mental hospital in Xinjiang set up a similar
farm. Ever since my retirement in 2009, I have
traveled widely to different provinces and
cities of mainland China to deliver talks on my
previous working experience, and I encourage
colleagues to come to Hong Kong to see how
we do things. This sort of exchange serves
to show visitors that people with a history of
mental illness can recover and hold down a
job like anyone else.
Naturally, social enterprises run by nonprofit
welfare organizations are limited; they
are “models” of best practice. My ultimate aim
is to encourage business firms to partner
with non-profit organizations to set up actual
small businesses that employ persons with
disabilities or to set up social enterprises
within their own firms. Such an endeavor
represents more than just corporate social
responsibility; it is a commitment to plough
back profits into a company to create employment
positions for the disadvantaged. That
is my vision, and I am optimistic that others
will share it. I am now seeing more young
entrepreneurs enter the field of social enterprise
with financial support from social ventures
providing seed money.
Social entrepreneurship has to be nurtured,
and optimally during young people’s
years at university. I have seen social entrepreneurship
being taken up by various business
schools at Hong Kong’s universities, but
the field still has a long way to go. Since the
enactment of the United Nations Convention
on the Rights of Persons with Disabilities in
2008, the interest of governments in this
area has been growing. Every effort should
be made to provide jobs through social enterprises.
I do hope that more young social
entrepreneurs will decide to go into business

GLOBAL INVESTOR 2.12 — 46
The future of healthcare
Watson
turns medic
More than a year after it won the quiz show, Jeopardy!, IBM’s supercomputer is learning how to help
doctors diagnose patients by mining and analyzing the growing volume of healthcare data. The
ultimate goal is to deliver better care, lower healthcare costs and to provide a tool suited to exploring
medical grand challenges.
Jim Giles, writer
The IBM Watson computer that won the quiz show, Jeopardy!, could
help doctors – already stressed by the vast amounts of information
they are expected to consume – to better diagnose patients. Researchers
estimate that the volume of medical knowledge doubles every five
years. This requires doctors, who are already pressed for time, to
spend their evenings and weekends reading medical journals, not to
mention the continuing education classes they are required to attend.
But despite their massive investment of time and energy, physicians
have no guarantee that a patient will present the same symptoms and
complications as described in the latest scholarly works and research.
No wonder that even the smartest physicians struggle to apply constantly
evolving medical knowledge to treat their patients.
Watson could help physicians with their data and information
dilemma by using content and predictive analytics to “uncover” hidden
diagnostic possibilities lurking in the reams of data. The computer can
cross-reference patient data and look for most successful treatments,
taking drug interactions and medical history into account.
Teaching a new dog newer tricks
It’s the same skill set that made Watson successful in Jeopardy! – the
ability to consider vast volumes of information. In the medical arena,
this includes textbooks, medical research and data about patient
populations and individuals. The computer is expected to be especially
useful in oncology, where physicians struggle to keep up with
the massive amounts of genomic and molecular data for each cancer
type. It potentially has applications elsewhere, such as in the insurance
arena, where the computer could be fed insurance guidelines
and patient history to determine whether a request follows company
policy. WellPoint, a large US insurer, is testing the system for these
purposes.
To date, the technology is most advanced in the cancer field, where
IBM is working with several US hospitals. Still, the technology is a
work in progress. IBM Watson scored 50% on its first test – the Doctor’s
Dilemma, a competition for trainee doctors. To improve the technology,
Watson is now absorbing tens of thousands of records from
Memorial Sloan-Kettering Cancer Center in New York. Physicians
could use the computer to analyze information about similar patients
and conditions, from recent scientific publications or from years of
patient records. The computer might suggest the next piece of information
needed to resolve a difficult diagnostic ambiguity in a case of
atypical symptoms and findings.
IBM Watson will never take the place of a physician, and not every
healthcare organization needs a powerful solution like this. But most
every organization has vast amounts of clinical and business data
going untapped. This data, when analyzed and used effectively, could
be mined for insight, enabling physicians and hospital administrators
to make sense of the enormous amount of data being created from
an increasingly instrumented healthcare world. The emergence of
new technology to mine and analyze the growing volume of structured
and unstructured healthcare data will help deliver better care, lower
healthcare costs, and help us explore the great medical challenges

I/8
II/13
III/34
IV/40
Beyond pills V
The virtual physician’s assistant
The information explosion has made it very difficult for a variety of
professionals to keep up, and physicians in particular struggle
to maintain their knowledge of the ever-growing field of biomedical
science. Increasingly, some are turning to high-powered computers
for help. Now doctors are experimenting with IBM’s Watson –
the supercomputer that defeated human contestants in the quiz
show “Jeopardy!” last year. The idea is to harness Watson’s computational
powers so it can serve as a virtual physician’s assistant.
Researchers say this may be especially useful in the cancer
tial growth in data.
Watson
Photo: IBM

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12C020A

GLOBAL INVESTOR 2.12 Services — 50
Imprint
Credit Suisse AG, Global Research,
P.O. Box 300, CH-8070 Zurich
Publisher
Giles Keating
Editors
Thomas C. Kaufmann, Markus Stierli
Editorial deadline
2 October 2012
Production management
Markus Kleeb, Katharina Schlatter
Concept
arnold.kircherburkhardt.ch
Design and realization
arnold.kircherburkhardt.ch
Angélique Bolter, Martin Blättler, Luzian Meier, Arno Bandli,
Benno Delvai, Sacha Steiner, Rahel Frick (project management)
Editorial support
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Copies of this publication may be ordered via your customer
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Cover photo: Pasieka/David Mack/Science Photo Library
neutral
Printed Matter
No. 01-12-105336 – www.myclimate.org
© myclimate – The Climate Protection Partnership

Order GI
-
GI 2.08
Beyond charity
GI 3.08
Return to a
multipolar world
GI 1.09
Building investment
strategies
GI 2.09
Global megatrends
ACP
-
-
-
-
-
-
-
-
-
-
-
-
-

GI 1.12
Design
GI 1.10
-
-
-
GI 2.10
Urbanization
GI 1.11
Emotions and markets
GI 2.11
Inheritance
80%
50%2050
-
-
-
-
-
-
-

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