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Very interesting article about a fascinating company that hopes to take advantage of digitalization within healthcare. Acurian certainly creates new opportunities for pharmaceutical companies, but I do wonder about the net cost savings of the product. They can shorten trial timelines, but there is also an incremental cost to use the software, and the possibilities they open up are themselves costly. For example, a 20-30 year longitudinal study of Alzheimer’s would certainly prove informative, but it seems unlikely to me that a pharma company would be willing to pay for such a large and long-term trial, which would undoubtedly be very costly. Similarly, identifying patients around the country would speed up trial recruitment, but would also require the recruitment and funding of many more clinical trial sites. These sites themselves can have logistical hurdles, especially for novel therapeutics that are very difficult to produce, ship, and administer correctly. Indeed, Kymriah, the product cited in your first paragraph, is only available at a select number of centers across the country, so finding incremental patients in, say, Nebraska may not have helped [1].

I’m also curious to learn more about Acurian’s patient identification algorithms. Where do they get their data on 17 million people and their health conditions? Are there privacy concerns associated with this that could have the potential for public backlash (e.g., if they’re tracking people’s Google searches)? How do they track the evolution of these conditions and these patients’ health records over time, since many trials are open only to certain sub-segments of a diseased population (e.g. treatment-refractory patients or patients with certain genetic markers)? Most importantly, do they have a repeatable and scalable way to continue getting data on new patients, or is this a static data set? This is important not only for expanding the database, but also because many trials aren’t open to patients who are receiving another experimental therapy, and because later-stage trials in diseases with very few patients may be hard to recruit for because most of the eligible and identifiable patients have already tried the therapy, underscoring the need for a constant inflow of new identified patients.

[1] “Find a Kymriah treatment center.” Novartis. Accessed November 30, 2017.

On November 30, 2017, Gabrielle commented on The Republic of Maldives is Sinking :

Fascinating content, JDW. Sadly, this is not even the first place that has succumbed to climate change – there have already been climate change refugees in Alaska, as one city was forced to relocate due to rising sea levels [1]. Obviously, this case is simpler as they were able to relocate to their own country, and even their home state, but this impact is already very real, and I agree with other commenters that action is unlikely to be taken anytime soon given the current state of international politics.

I wonder if the Maldives has contingency plans for if and when their island is no longer able to exist. Will they be able to find land to relocate to en masse, and if they do, will they maintain sovereignty or become a territory of another nation? What will the international relations implications be? Which country is willing to give up part of their land to citizens of another country?

[1] Mele, Christopher and Daniel Victor. “Reeling from effects of climate change, Alaskan village votes to relocate.” The New York Times. Accessed November 30, 2017.

Fascinating article, VK. I agree with you and others that I’m surprised CVS hasn’t taken a more offensive position on this, given what a risk it presents to their business – in addition to their pharmacy business, I also imagine that there must be substantial incremental revenue in their drugstores that is driven by the foot traffic from in-store pharmacies. I wonder if a future combined CVS/Aetna entity could take more aggressive defensive action – for example, could they refuse to pay claims filed by Amazon or other pharmacies that ship the product to the consumer, thereby forcing consumers to brick-and-mortar pharmacies? This may seem far-fetched, but some health plans already have preferred and non-preferred pharmacies, and CVS Caremark is one of the biggest PBMs in the country, while Aetna is one of the biggest payers.

I also think about the role of other intermediaries in the supply chain. What would Amazon’s potential future success with direct-to-consumer prescription delivery mean for pharmaceutical wholesalers / drug distributors? Would they still exist, or if Amazon succeeds in dominating this market, could they deal directly with the pharmaceutical manufacturers? What is the pharmacist’s role in all of this? And there is also a question of legal liability. When I go pick up a drug at a brick-and-mortar pharmacy, I have to sign a waiver that I’ve been offered the opportunity to speak with a pharmacist about how to use my treatment correctly. How would this work with direct-to-consumer delivery, and if a patient does misuse a drug that was shipped from Amazon to their house, who is legally liable for this miscommunication?

On November 30, 2017, Gabrielle commented on Jumping through hoops: Cirque du Soleil in an era of isolationism :

Great post, Kimia – a refreshing and unique take on the trend of isolationism, and it’s very interesting to see how Cirque du Soleil is diversifying away from a sole reliance on acrobatics. However, the Cirque du Soleil brand is still synonymous with the traditional acrobatics shows that the company became known for, and as you note, its core business still relies on sourcing artistic talent, so this will not provide a complete short-term solution.

Many of the suggested solutions have been on the demand side, i.e. reducing Cirque du Soleil’s need for these uniquely talented artists. I wonder if supply-side solutions also have a role to play. Cirque du Soleil could expand artist training programs, perhaps hiring additional understudies to expand the artist pipeline or sponsoring a course for talented amateur circus artists. Thinking more long-term, Cirque du Soleil could partner with circus schools to identify talent at a young age and provide development opportunities for these artist-athletes, or even consider broadening its own network of circus schools. While these solutions would undoubtedly incur cost, they could also yield benefits beyond immigration issues by expanding the Cirque du Soleil network and the future pool of talent to draw upon for Cirque du Soleil shows.

Great read, Maud. It’s interesting to see the suggestions in your essay, as well as from TS and Sara, that Airbus could consider relocating more of its manufacturing to the U.S. Airbus has actually just ramped up its U.S. manufacturing operation in my home state of Alabama via its deal with Bombardier, which sees it take a majority stake in Bombardier’s C-Series airliner business so that their planes can be produced in the U.S. rather than produced abroad and forced to face Trump’s import tariffs – another example of isolationist movements on this side of the pond [1]. Given this, I wonder if there remains any additional capacity to produce more Airbus jets in the U.S. without the huge capital expenditure required to build a new plant and all the associated ramp-up costs. I would be interested to see how they would weigh opening a new plant in the U.S., with local talent already identified to help train new staff but higher costs, versus shifting to China as mp.osorio has highlighted.

[1] Reid, David. “Boeing versus Bombardier: here’s what happens next.” Accessed on November 30th, 2017.

Fascinating piece about an oft-overlooked industry. I am particularly struck by Exhibit 1’s visualization of how little overlap there is between areas suitable for grape growing now vs. in 2050. As a wine consumer, I look forward to seeing what innovations in grape varietals and types of wine come out of this.

You mention that grapes will have to be grown in new geographies in the future. I wonder how the need to shift production to new countries will change the structure of the supply chain. I imagine there will be significant ‘set-up’ and ramp-up time to plant new grapes and scale up production in new geographies. Will this benefit incumbent small wineries in those regions, or will large vineyards still win out with their superior resources and knowledge? Will this lead to the rise of additional players in the supply chain, such as businesses that specialize in raw materials production (i.e. growing grapes) and ship them to traditional vineyards for the actual wine production?

Moreover, how will the institutions of traditional wine regions, especially where tourism is a significant contributor to the economy (e.g. Bordeaux, the Loire Valley, Napa Valley), respond to this inevitable threat? Perhaps they will pursue technological innovation rather than shifting their geography. I know that Iceland is able to produce a meaningful portion of its food domestically thanks to greenhouses that provide a more suitable climate – maybe wineries will be able to invest in climate-controlled facilities to continue growing grapes in their natural terroir.