How ‘ghost work’ in Silicon Valley pressures the workforce, with Mary Gray

The phrase “pull yourself up by your own bootstraps” was originally meant sarcastically.

It’s not actually physically possible to do — especially while wearing Allbirds and having just fallen off a Bird scooter in downtown San Francisco, but I should get to my point.

This week, Ken Cuccinelli, the acting Director of the United States Citizenship and Immigrant Services Office, repeatedly referred to the notion of bootstraps in announcing shifts in immigration policy, even going so far as to change the words to Emma Lazarus’s famous poem “The New Colossus:” no longer “give me your tired, your poor, your huddled masses yearning to breathe free,” but “give me your tired and your poor who can stand on their own two feet, and who will not become a public charge.”

We’ve come to expect “alternative facts” from this administration, but who could have foreseen alternative poems?

Still, the concept of ‘bootstrapping’ is far from limited to the rhetorical territory of the welfare state and social safety net. It’s also a favorite term of art in Silicon Valley tech and venture capital circles: see for example this excellent (and scary) recent piece by my editor Danny Crichton, in which young VC firms attempt to overcome a lack of the startup capital that is essential to their business model by creating, as perhaps an even more essential feature of their model, impossible working conditions for most everyone involved. Often with predictably disastrous results.

It is in this context of unrealistic expectations about people’s labor, that I want to introduce my most recent interviewee in this series of in-depth conversations about ethics and technology.

Mary L. Gray is a Fellow at Harvard University’s Berkman Klein Center for Internet and Society and a Senior Researcher at Microsoft Research. One of the world’s leading experts in the emerging field of ethics in AI, Mary is also an anthropologist who maintains a faculty position at Indiana University. With her co-author Siddharth Suri (a computer scientist), Gray coined the term “ghost work,” as in the title of their extraordinarily important 2019 book, Ghost Work: How to Stop Silicon Valley from Building a New Global Underclass. 

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Image via Mary L. Gray / Ghostwork / Adrianne Mathiowetz Photography

Ghost Work is a name for a rising new category of employment that involves people scheduling, managing, shipping, billing, etc. “through some combination of an application programming interface, APIs, the internet and maybe a sprinkle of artificial intelligence,” Gray told me earlier this summer. But what really distinguishes ghost work (and makes Mary’s scholarship around it so important) is the way it is presented and sold to the end consumer as artificial intelligence and the magic of computation.

In other words, just as we have long enjoyed telling ourselves that it’s possible to hoist ourselves up in life without help from anyone else (I like to think anyone who talks seriously about “bootstrapping” should be legally required to rephrase as “raising oneself from infancy”), we now attempt to convince ourselves and others that it’s possible, at scale, to get computers and robots to do work that only humans can actually do.

Ghost Work’s purpose, as I understand it, is to elevate the value of what the computers are doing (a minority of the work) and make us forget, as much as possible, about the actual messy human beings contributing to the services we use. Well, except for the founders, and maybe the occasional COO.

Facebook now has far more employees than Harvard has students, but many of us still talk about it as if it were little more than Mark Zuckerberg, Cheryl Sandberg, and a bunch of circuit boards.

But if working people are supposed to be ghosts, then when they speak up or otherwise make themselves visible, they are “haunting” us. And maybe it can be haunting to be reminded that you didn’t “bootstrap” yourself to billions or even to hundreds of thousands of dollars of net worth.

Sure, you worked hard. Sure, your circumstances may well have stunk. Most people’s do.

But none of us rise without help, without cooperation, without goodwill, both from those who look and think like us and those who do not. Not to mention dumb luck, even if only our incredible good fortune of being born with a relatively healthy mind and body, in a position to learn and grow, here on this planet, fourteen billion years or so after the Big Bang.

I’ll now turn to the conversation I recently had with Gray, which turned out to be surprisingly more hopeful than perhaps this introduction has made it seem.

Greg Epstein: One of the most central and least understood features of ghost work is the way it revolves around people constantly making themselves available to do it.

Mary Gray: Yes, [What Siddarth Suri and I call ghost work] values having a supply of people available, literally on demand. Their contributions are collective contributions.

It’s not one person you’re hiring to take you to the airport every day, or to confirm the identity of the driver, or to clean that data set. Unless we’re valuing that availability of a person, to participate in the moment of need, it can quickly slip into ghost work conditions.

The UK’s National Health Service is launching an AI lab

The UK government has announced it’s rerouting £250M (~$300M) in public funds for the country’s National Health Service (NHS) to set up an artificial intelligence lab that will work to expand the use of AI technologies within the service.

The Lab, which will sit within a new NHS unit tasked with overseeing the digitisation of the health and care system (aka: NHSX), will act as an interface for academic and industry experts, including potentially startups, encouraging research and collaboration with NHS entities (and data) — to drive health-related AI innovation and the uptake of AI-driven healthcare within the NHS. 

Last fall the then new in post health secretary, Matt Hancock, set out a tech-first vision of future healthcare provision — saying he wanted to transform NHS IT so it can accommodate “healthtech” to support “preventative, predictive and personalised care”.

In a press release announcing the AI lab, the Department of Health and Social Care suggested it would seek to tackle “some of the biggest challenges in health and care, including earlier cancer detection, new dementia treatments and more personalised care”.

Other suggested areas of focus include:

  • improving cancer screening by speeding up the results of tests, including mammograms, brain scans, eye scans and heart monitoring
  • using predictive models to better estimate future needs of beds, drugs, devices or surgeries
  • identifying which patients could be more easily treated in the community, reducing the pressure on the NHS and helping patients receive treatment closer to home
  • identifying patients most at risk of diseases such as heart disease or dementia, allowing for earlier diagnosis and cheaper, more focused, personalised prevention
  • building systems to detect people at risk of post-operative complications, infections or requiring follow-up from clinicians, improving patient safety and reducing readmission rates
  • upskilling the NHS workforce so they can use AI systems for day-to-day tasks
  • inspecting algorithms already used by the NHS to increase the standards of AI safety, making systems fairer, more robust and ensuring patient confidentiality is protected
  • automating routine admin tasks to free up clinicians so more time can be spent with patients

Google-owned UK AI specialist DeepMind has been an early mover in some of these areas — inking a partnership with a London-based NHS trust in 2015 to develop a clinical task management app called Streams that’s been rolled out to a number of NHS hospitals.

UK startup, Babylon Health, is another early mover in AI and app-based healthcare, developing a chatbot-style app for triaging primary care which it sells to the NHS. (Hancock himself is a user.)

In the case of DeepMind, the company also hoped to use the same cache of NHS data it obtained for Streams to develop an AI algorithm for earlier detection of a condition called acute kidney injury (AKI).

However the data-sharing partnership ran into trouble when concerns were raised about the legal basis for reusing patient data to develop AI. And in 2017 the UK’s data watchdog found DeepMind’s partner NHS trust had failed to obtain proper consents for the use of patients’ data.

DeepMind subsequently announced its own AI model for predicting AKI — trained on heavily skewed US patient data. It has also inked some AI research partnerships involving NHS patient data — such as this one with Moorfields Eye Hospital, aiming to build AIs to speed up predictions of degenerative eye conditions.

But an independent panel of reviewers engaged to interrogate DeepMind’s health app business raised early concerns about monopoly risks attached to NHS contracts that lock trusts to using its infrastructure for delivering digital healthcare.

Where healthcare AIs are concerned, representative clinical data is the real goldmine — and it’s the NHS that owns that.

So, provided NHSX properly manages the delivery infrastructure for future digital healthcare — to ensure systems adhere to open standards, and no single platform giant is allowed to lock others out — Hancock’s plan to open up NHS IT to the next wave of health-tech could deliver a transformative and healthy market for AI innovative that benefits startups and patients alike.

Commenting on the launch of NHSX in a statement, Hancock said: “We are on the cusp of a huge health tech revolution that could transform patient experience by making the NHS a truly predictive, preventive and personalised health and care service.

“I am determined to bring the benefits of technology to patients and staff, so the impact of our NHS Long Term Plan and this immediate, multimillion pound cash injection are felt by all. It’s part of our mission to make the NHS the best it can be.

“The experts tell us that because of our NHS and our tech talent, the UK could be the world leader in these advances in healthcare, so I’m determined to give the NHS the chance to be the world leader in saving lives through artificial intelligence and genomics.”

Simon Stevens, CEO of NHS England, added: “Carefully targeted AI is now ready for practical application in health services, and the investment announced today is another step in the right direction to help the NHS become a world leader in using these important technologies.

“In the first instance it should help personalise NHS screening and treatments for cancer, eye disease and a range of other conditions, as well as freeing up staff time, and our new NHS AI Lab will ensure the benefits of NHS data and innovation are fully harnessed for patients in this country.”

The Pill Club is donating 5,000 units of emergency contraception

Eleven million women in the U.S. live more than an hour from an abortion clinic, a number expected to increase as facilities close up shop following new restrictions on women’s healthcare in several states.

Planned Parenthood and other leading nonprofits continue to put up a good fight while private “mission-driven” companies in the burgeoning women’s health tech sector are all talk and little action. But a new effort from The Pill Club, an Alphabet-backed birth control and prescription delivery startup, may lead to change in the nascent sector.

The Pill Club has partnered with Power To Decide, a nonprofit campaign to prevent unplanned pregnancies, to dole out free emergency contraception to women in need. Together they’ll distribute 5,000 units of a generic form of Plan B, a pill taken after sex to stop a pregnancy before it starts. For the next three months The Pill Club will also match all donations up to $10,000 made to Power To Decide’s Contraceptive Access Fund, which helps low-income women access contraception. Anyone can sign up now to receive free units.

The Pill Club’s decision to share resources with a nonprofit comes as several states this year have imposed new laws restricting or outlawing abortion procedures. Alabama, for example, earlier this year passed a Senate bill banning abortion in the state. Arkansas, Indiana, Kentucky and others have also OK’d new restrictions on abortion.

The Pill Club

This is The Pill Club’s first effort to donate emergency contraception to populations in need, as well as its first partnership with a not-for-profit entity. Co-founder and chief executive officer Nick Chang says the startup thought long and hard about how it could be most helpful to women in this political climate.

“We thought, what can we do to support women in these states in ways that other companies may not be able to?,” Chang tells TechCrunch. “This is the moment where private companies can really go out and benefit women in ways that may not be supported in other avenues. Since we have the means and ability to do it in ways that are more convenient and private, it’s our opportunity to drive access and support.”

Founded in 2014 and backed with more than $60 million in venture capital funding, one might argue The Pill Club should have forged partnerships like this from the get-go. Curious what efforts other well-funded birth control startups were making to support women in 2019, especially women in contraceptive deserts who are likely unfamiliar with the new line of consumer birth control brands, I reached out to The Pill Club’s competitors Nurx, a fellow birth control delivery company, and Hers, a line of women’s healthcare products owned by the billion-dollar startup Hims.

Both companies emphasized the fact that many of their customers live in Southern states, or the region most impacted by new limitations to abortion care, but didn’t mention any new efforts to increase access, like partnerships with nonprofits or donations. Hers provided this quote from the company’s co-founder Hilary Coles, which didn’t answer my question but did make clear the company is thinking about serving contraceptive deserts:

“At Hers, our mission is to provide women with more convenient and affordable access to the healthcare system,” Hers co-founders Hilary Coles said in a statement. “Approximately 3.5 million patients go without care because they cannot access transportation to their providers and 19.5 million women have reported not having access to a clinic that provides birth control specifically. That’s simply unacceptable. Closing the gaps caused by geographic barriers between patients and their doctors was one of the primary challenges we set out to address when founding Hers. We’re proud to be a resource for women nationwide, including those who live in contraceptive deserts who may not otherwise have access to the care they need. It’s crucial to Hers to be part of the solution in alleviating the pain points women experience within the healthcare system.” 

It’s not the responsibility of these companies to improve the political landscape of the U.S., but with $340 million in private capital shared between them, the trio does have a unique opportunity to innovate, share, collaborate and influence. After all, that’s what’s so great about healthtech; it brings new, innovative solutions to an industry characterized by antiquated systems and slow movers. For once, Silicon Valley’s “move fast and break things” mantra may be appropriately applied to a facet of healthcare. Women need sustained access to contraception and abortion care. Fast.

“This is the time when private companies can step in,” Chang concluded. “We can come in and help out and it’s our responsibility to do that.”

What tech gets right about healthcare

Why is tech still aiming for the healthcare industry? It seems full of endless regulatory hurdles or stories of misguided founders with no knowledge of the space, running headlong into it, only to fall on their faces.

Theranos is a prime example of a founder with zero health background or understanding of the industry — and just look what happened there! The company folded not long after founder Elizabeth Holmes came under criminal investigation and was barred from operating in her own labs for carelessly handling sensitive health data and test results.

But sometimes tech figures it out. It took years for 23andMe to breakthrough FDA regulations — it’s since more than tripled its business and moved into drug discovery.

And then there’s Oscar Health, which first made a mint on Obamacare and has since ventured into Medicare. Combined with Bright, the two health insurance startups have pulled in a whopping $3 billion so far.

It’s easy to shake our fists at fool-hardy founders hoping to cash in on an industry that cannot rely on the old motto “move fast and break things.” But it doesn’t have to be the code tech lives or dies by.

So which startups have the mojo to keep at it and rise to the top? Venture capitalists often get to see a lot before deciding to invest. So we asked a few of our favorite health VC’s to share their insights.

Phin Barnes – First Round Capital

CRV hires Anna Khan as a general partner focused on enterprise

CRV, formerly known as Charles River Ventures, has hired Anna Khan as its 10th general partner. Khan joins from Bessemer Venture Partners where she’s served as a vice president since 2016.

CRV invests across industries, with a portfolio that includes Bird and Airtable, among others. The venture capital firm is currently investing out of its 17th fund, a $600 million vehicle that closed in 2018.

Founded in 1970, CRV is amongst the older VC firms. While Khan isn’t the firm’s first female GP — Annie Kadavy, now a general partner at Redpoint Ventures, joined CRV as a GP in 2012 — she will be the firm’s only current female GP.

Despite, an increasing number of firms tapping female talent, less than 10% of “decision-makers” at U.S. venture capital firms are female, according to Axios. Female founders, meanwhile, attract just over 2% of venture capital dollars.

Khan joins CRV alongside another new hire, former Social Capital partner Kristin Baker Spohn. Both Khan and Spohn, a venture partner, will focus on CRV’s enterprise practice, where they’ll work with Airtable, Drift, Iterable, SignalFx and more.

Kristin Baker Spohn

CRV’s newest venture partner Kristin Baker Spohn

“As is often the case, we were introduced to both [Khan and Spohn] through friends of CRV, and from our earliest conversations knew they would add tremendously to the firm,” CRV general partner Murat Bicer said in a statement. “Kristin brings an impressive depth of knowledge in healthcare and a charisma that speaks to early entrepreneurs and seasoned executives alike, while Anna has an immense understanding of the SaaS world and an energy that has seen her accomplish so much in a relatively short period of time.”

Khan, an investor in ScaleFactor, NewVoiceMedia and Intercom, previously founded Launch X, an accelerator that helps female entrepreneurs learn how to raise capital for their businesses.

Spohn’s been an active angel investor since leaving Social Capital. She exited the once high-flying venture capital fund last year following Social Capital co-founder Chamath Palihapitiya’s decision to no longer raise outside capital.

Trueface raises $3.7M to recognise that gun, as it’s being pulled, in real time

Globally, millions of cameras are in deployed by companies and organizations every year. All you have to do is look up. Yes, there they are! But the petabytes of data collected by these cameras really only become useful after something untoward has occurred. They can very rarely influence an action in “real-time”.

Trueface is a US-based computer vision company that turns camera data into so-called ‘actionable data’ using machine learning and AI by employing partners who can perform facial recognition, threat detection, age and ethnicity detection, license plate recognition, emotion analysis as well as object detection. That means, for instance, recognising a gun, as it’s pulled in a dime store. Yes folks, welcome to your brave new world.

The company has now raised $3.7M from Lavrock Ventures, Scout Ventures, and Advantage Ventures to scale the team growing partnerships and market share.

Trueface claims it can identify enterprises’ employees for access to a building, detect a weapon as it’s being wielded, or stop fraudulent spoofing attempts. Quite some claims.

However, it’s good enough for the US Air Force as it recently partnered with them to enhance base security.

Originally embedded in a hardware access control device, Trueface’s computer vision software inside one of the first ‘intelligent doorbell’, Chui which was covered by TechCrunch’s Anthony Ha in 2014.

Trueface has multiple solutions to run on an array of clients’ infrastructures including a dockerized container, SDKs that partners can use to build their own solutions with, and a plug and play solution that requires no code to get up and running.

The solution can be deployed in various scenarios such as fintech, healthcare, retail to humanitarian aid, age verification, digital identity verification and threat detection. Shaun Moore and Nezare Chafni are the cofounders and CEO and CTO, respectively.

The computer vision market was valued at USD 9.28 billion in 2017 and is now set to reach a valuation of USD 48.32 billion by the end of 2023.

Facial recognition was banned by agency use in the city of San Francisco recently. There are daily news stories about privacy concerns of facial recognition, especially in regards to how China is using computer vision technology.

However, Truface is only deployed ‘on-premise’ and includes features like ‘fleeting data’ and blurring for people who have not opted-in. It’s good to see a company building in such controls, from the word go.

However, it’s then it’s up to the company you work for not to require you to sign a statement saying you are happy to have your face recognized. Interesting times, huh?

And if you want that job, well, that’s a whole other story, as I’m sure you can imagine.

SoftBank pumps $2B into Indonesia through Grab investment, putting it head to head with Gojek

Grab — the on-demand transportation app worth $14 billion that is the Uber of Southeast Asia — today announced how it would be using some of the $7 billion or so that it has raised to date: $2 billion provided by SoftBank is being earmarked Grab’s operations in Indonesia — the biggest economy in Southeast Asia — over the next five years, to help it go head-to-head with local rival Gojek.

Specifically, Grab said it and SoftBank met with Indonesian government officials and have agreed to use the money to help modernise the country’s transportation infrastructure and economy with the development of an electronic vehicle “ecosystem”, new geo-mapping solutions, and the establishment of a second headquarters for Grab in Jakarta focused on R&D for Indonesia and the wider region, to sit alongside its existing HQ in Singapore.

Grab has confirmed that this investment news does not affect the company’s valuation as it’s not fresh funding — although it looks like it might lead to another, new SoftBank injection in Grab, too.

“I’d like to invest more… We would invest (in) Grab more, and also encourage to invest more in other companies,” SoftBank CEO Masayoshi Son said in a press conference earlier today. “We will create a second headquarters of Grab in Indonesia, and become 5th unicorn and also invest $2b through Grab. On top of that, we will invest more.”

Grab last raised money just four weeks ago, $300 million from Invesco as part of a larger, ongoing Series H that it wants to use in part for acquisitions. That round is already at around $4.5 billion, with SoftBank having already put in just under $1.5 billion. This $2 billion is on top of that previous round, the company said today.

The company’s last reported valuation from a couple of months ago was around $14 billion, a figure that we have been able to confirm remains the same today.

“With our presence in 224 cities, Indonesia is our largest market and we are committed to long-term sustainable development of the country,” said Anthony Tan, CEO of Grab, in a statement. “We are delighted to facilitate this SoftBank investment, as we believe by investing in digitizing critical services and infrastructure, we hope to accelerate Indonesia’s ambition to become the largest digital economy in the region and improve the livelihoods of millions in the country.” Indonesia accounts for the lion’s share of Grab’s business in terms of total footprint: its in 338 countries overall, meaning this country accounts for two-thirds of the whole list.

The news puts Grab head to head with another big on-demand transportation startup Gojek: the two were already rivals in the region, but GoJek is based out of Jakarta and has been the dominant player in that specific market up to now.

Indeed, the deal is notable not just for the amount, but for how it casts both Grab and SoftBank as allies of the government, not just accepted as businesses but endorsed as key players in helping improve the Indonesian economy and how the country is able to deliver critical services like healthcare and transportation, as well as give more services to drive the growth of “micro-entrepreneurs” by way of Grab-Kudo, the payments startup in the country that Grab acquired in 2017 for less than $100 million.

Given the track record that companies like Uber have had in locking horns with regulators, this puts Grab immediately into a strong position in terms of introducing and running with new services in the future. Its restaurant delivery business, GrabFood, is already the largest in the region, it claimed today.

Grab said the financial commitment was the result of a meeting between Indonesia’s President Joko Widodo, Masayoshi Son, Chairman & CEO of SoftBank Group, Anthony Tan, CEO of Grab and Ridzki Kramadibrata, President of Grab Indonesia, at the Merdeka Palace in Jakarta.

“Indonesia’s technology sector has huge potential,” said Son in a statement. “I’m very happy to be investing $2 billion into the future of Indonesia through Grab.”

Indonesia’s Coordinating Minister for Maritime Affairs Luhut Binsar Panjaitan also had words supporting the deal: “Supported by the growing economy, Indonesia has a good investment climate where we are working together to boost the ease of investment in Indonesia,” he said. “This investment is evidence that Indonesia has been on the radar of investors, especially in the technology sector. We look forward to working with Grab, the fifth unicorn in Indonesia, and SoftBank to empower SMEs, accelerate tourism, and improving health services.”

This deal is a win on a couple of levels for Grab.

Most obviously, it’s giving the company a huge injection of capital to continue expanding its business aggressively in what is the biggest economy in Southeast Asia, with GDP of around $1 trillion annually.

A well-worn strategy by on-demand transportation companies — typified by others like Uber, Lyft and Didi — is to go big and go fast in order to establish a market presence among drivers and passengers, which can be used as a foothold to expand into other areas like food or package delivery and to then increase prices to improve margins.

Given that Indonesia is Gojek’s home country, and given that Indonesia is one of the biggest markets in the region, this makes it one of the most important territories for Grab to — err — grab.

“Grab is an Indonesia-focused company,” said Ridzki Kramadibrata, president of Grab Indonesia, in a statement today. “Having our second headquarters in Jakarta will allow us to better serve the needs of all Indonesians and those from emerging economies in the region. As a technology decacorn, Grab very well understands the needs and challenges we have here. We are also well positioned to support more high tech industries and infrastructure companies originating from Indonesia.”

On another front, this is an important strategy for the company on the regulatory and government front.

In a climate where it’s not unusual to see companies banned from operating in markets where they have run afoul of officials and the public, Grab is essentially buying its way into working with the state, and actually taking a commercial role in building its infrastructure. This — offering help with building infrastructure and simply passing on some of its experience and learnings — is a route that Didi has also been taking to make its way into new markets.

Grab said that it has invested $1 billion to date in Indonesia before now, and it said that its contribution to the economy in 2018 was $3.5 billion (48.9 trillion Indonesian rupiahs).

Updated to clarify that this is NOT a new infusion of capital, but a specification of how existing investments will be used. Meanwhile, Grab is still raising money and SoftBank said it wants to invest more.

Last-mile training and the future of work in an expanding gig economy

The future of work is so uncertain that perhaps the only possible job security exists for the person who can credibly claim to be an expert on the future of work.

Nevertheless, there are two trends purported experts are reasonably certain about: (1) continued growth in the number of jobs requiring substantive and sustained interaction with technology; and (2) continued rapid expansion of the gig economy.

This first future of work trend is evident today in America’s skills gap with 7 million unfilled jobs — many mid- or high-skill position requiring a range of digital and technology capabilities.

Amazon’s recent announcement that it will spend $700 million over the next six years to upskill 100,000 of its low-wage fulfillment center employees for better digital jobs within Amazon and elsewhere demonstrates an understanding that the private sector must take some responsibility for the requisite upskilling and retraining, as well as the importance of establishing pathways to these jobs that are faster and cheaper than the ones currently on offer from colleges and universities.

These pathways typically involve “last-mile training”, a combination of digital skills, specific industry or enterprise knowledge, and soft skills to make candidates job-ready from day one.

The second trend isn’t new; the gig economy has existed since the advent of the “Help Wanted” sign. But what’s powered the gig revolution is the shift from signs and classified ads to digital platforms and marketplaces that facilitate continued and repeated matching of gig and gig worker. These talent platforms have made it possible for companies and organizations to conceptualize and compartmentalize work as projects rather than full-time jobs, and for workers to earn a living by piecing together gigs.

Critics of the gig economy decry the lack of job security, healthcare and benefits, and rightly so. If it’s hard to make ends meet as a full-time employee making a near-minimum wage, it’s impossible to do so via a gig platform at a comparable low wage. But rather than fighting the onset of the gig economy, critics might achieve more by focusing on upskilling gig workers.

To date, conversations about pathways and upskilling have focused on full-time employment. In the workforce or skills gap vernacular, upskilled Amazon workers might leave the fulfillment center for a tech support job with Amazon or another company, but it’s always a full-time job. But how do these important concepts intersect with the rising gig economy?

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Image via Getty Images / PeterSnow

Just as there are low-skill and high-skill jobs, there are gig platforms that require limited or low skills, and platforms that require a breadth of advanced skills. Gig platforms that can be classified as low-skill include Amazon’s Mechanical TurkTaskRabbitUber and Lyft, and Instawork (hospitality). There are also mid-tier platforms like Upwork that span a wide range of gigs. And then there are platforms like Gigster (app development), and Business Talent Group (consulting and entire management functions) that require the same skillset as the most lucrative, in-demand, full-time positions.

So just as Amazon is focused on last-mile training programs to upskill workers and create new pathways to better jobs, in the gig economy context, our focus should be on strategies and platforms that allow gig workers to move from lower-skill to higher-skill platforms i.e., pathways for Uber drivers to become Business Talent Group executives.

One high-skill gig platform has developed an innovative strategy to do exactly this. CreatorUp is a gig platform for digital video production that has built in a last-mile training on-ramp. CreatorUp offers low-cost or free last-mile training programs on its own and in conjunction with clients like YouTube and Google to upskill gig workers so they can be effective digital video producers on the CreatorUp platform.

CreatorUp’s programs are driven by client demand; because the company saw significant demand from clients for AR/VR video production, it launched a new AR/VR training track. Graduates of CreatorUp’s programs join the platform and are staffed on a wide range of productions that clients require to engage customers, suppliers, employees and/or to build their brands.

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The good news for CreatorUp and other high-skill gig platforms that begin to incorporate last-mile training is that investing in these pathways can start the flywheel that every successful talent marketplace requires. Clients only patronize talent marketplaces once there’s a critical mass of talent on the platform. So how do platforms attract talent? One way is to be first-to-market in a category. A second is to attract billions in venture capital. But a third might be to use last-mile training to create new talent.

CreatorUp believes its last-mile training programs have allowed it to grow a network that serves diverse client needs better than any other video production platform. For not only has last-mile training allowed CreatorUp to understand and certify the skills of talent on the platform, and therefore to meet the needs of more clients, it has also allowed CreatorUp to bid more competitively because newly trained talent is often willing to work for less.

Last-mile training has the potential to be a win-win for the gig economy. It’s a strategy that may allow gig platforms to scale, matching more talent with more clients. Meanwhile, by allowing workers to upskill from lower-tier gig platforms to higher skill platforms, it’s also the first gig economy solution for social mobility.

Healthcare startups struggle to navigate a business world that’s set up for them to fail

Digital health startups seem to be struggling to the point of failure. Many insights into why have addressed how technology’s traditional model of quickly putting out a minimum viable product then finding useful applications and business models isn’t working. The model might work in the general technology startup space, but it rarely goes well in the complex world of healthcare. Dr. Paul Yock, a cardiologist and founder of the Byers Center for Biodesign at Stanford University, built his brainchild program on one philosophy to help healthcare startups: need-based innovation.

Need-based innovation is a process in which problems are identified and sorted based on impact and opportunity. Once the top problem has been selected, solutions and commercialization are approached.

While I completely agree with need-based innovation, our healthcare system is set up to discourage all forms of  innovation right now. We also must tackle changing the ecosystem that healthcare startups need to navigate. As a physician-innovator, I have experienced how institutional policies, hierarchical and administrator-driven systems and pilot program dynamics are creating a stunted ecosystem that is not reaching its full potential.

When approaching any stakeholder a health startup usually works with — an advisor, a healthcare system, a pilot site — the wheel often needs to be reinvented. The entrepreneur is faced with a time-consuming and costly disadvantage that frequently forces them to enter deals that hurt them. The deals also counter-intuitively hurt the stakeholder that they are bringing on board because the technologies and companies on which they are counting are set up to fail. There needs to be a clear set of rules for everyone to play by to accelerate growth, with the philosophy that “a rising tide lifts all boats.”

These are the most crushing challenges of the current ecosystem that need a hard look and innovation themselves before healthcare startups can deliver.

Challenge 1: Institutional policies and hierarchical systems stunt innovation

Many healthcare startups are born during a founder’s time at a healthcare or educational institution. The institution promises to foster the innovation and make the nuances of the legal landscape easier. However, institutional innovation policies are not optimized to foster innovation, but rather to maximize ownership and financial returns. Most policies will require all filed patents to run through a “Tech Transfer Office,” which is assumed to provide value by performing Freedom to Operate searches and helping file for provisional patents.

Unfortunately, in today’s world of software, patents are somewhat less valuable and relevant than they once were. If any IP is filed, the institution will claim ownership and will consider licensing it to the inventor for a royalty agreement. Sometimes, if the institution does not believe in the ability of the inventor to carry the IP forward to commercialization, they will even cut them out entirely from the agreement.

An additional approach that is becoming more common within innovation policies is an equity stake in any companies started by an institutional employee, regardless of the existence of IP or whether the institution was interested in it. All of the above scenarios obviously take more from the healthcare startup than they give before an innovator even has time to blink.

Challenge 2: Healthcare doesn’t understand early-stage tech companies

Why are these policies designed this way? Part of the problem stems from stakeholders confusing medical technology with biotechnology (aka pharma). The innovation pathway within biotech is very well-defined, with established business models, established precedent and understandable risk profiles. It is quite common for drug discovery to start in the academic setting. Investors, boards and executive teams are accustomed to this model and can plan accordingly. Licensing patents and collecting a royalty on biotech sales is a market norm.

When it comes to early-stage technology companies, their challenges and early development are drastically different. The two critical resources an early-stage company has are cash and time. The goal is to unlock additional capital with product-market fit, and these companies need maximum flexibility to be able to move quickly to find it. Unfortunately, investors see the healthcare space as complex and high risk, which is true. So these startups face fundraising challenges for the space they are in, as well as unnecessary additional hurdles from the home institutions, increasing the likelihood of scaring away already skittish investors.

Challenge 3: Pilots are set up to hurt more than help

Startups are often completely dependent on partnerships or deals with larger healthcare organizations in order to grow and survive. These deals often start with a pilot. Unfortunately, the dynamic between giant healthcare institutions and tiny idealistic startups for pilots is not actually set up to be mutually beneficial.

In this scenario, healthcare systems have nothing to lose, orders of magnitude more resources and seemingly infinite amounts of time. Their incentive is to differentiate and “own” unique technologies so their competitors cannot get their hands on them. This is where startups often and understandably can make a big mistake — they believe the partner brings more value to the table than they do. For example, just having a pilot, even if it’s unpaid, with a major institution seems like it could help win over investors or additional customers. This leads to a spiral of events that frequently ends in sending startups into a trajectory toward failure (aka death by pilots).

We need innovators and administrators to come together and agree on common standards and rules to make the process more efficient, fair and effective.

Due to the lack of urgency and the intense bureaucracy, the sales cycle is long, sometimes one to two years, often lasting longer than startups have cash left to burn. Second, as mentioned, the pilot is frequently unpaid, or I have seen situations where an institution will even charge a startup for a pilot, leading to less cash and equity, which is already in short supply. Finally, onerous terms are often instituted, in which companies agree to unnecessary exclusivity or impossible goals. This doesn’t even take into consideration the challenges around deployment with HIPAA, security concerns and data sharing.

The ultimate result is that healthcare institutions that want to add value to their system by improving outcomes and decreasing costs will often doom the very technologies they believe are worthwhile. This dynamic is so well-established that many investors, even those well-versed in healthcare, will refuse to invest in institutional-oriented technology companies. My company, Osso VR, has had representatives of hospital systems approach us saying, “Don’t work with us. It will kill your company.”

Promising opportunities ahead

What if innovation policies were designed so that instead of focusing on what they can take from their spin-out companies, they focus on what value they can add? Stanford’s StartX accelerator program has a model where they commit to investing in 10% of any round a company raises after they leave the program, but it’s up to the company to choose whether or not they want StartX to participate. Unsurprisingly, almost all companies take advantage of the investment offer. These incentives help companies succeed and allow StartX to share in that success.

We need innovators and administrators to come together and agree on common standards and rules to make the process more efficient, fair and effective. One example we might follow is from Y Combinator. Raising money used to be expensive due to the amount of confusing legal documents required and corresponding legal fees. The time and expense could sometimes cause a deal to fall through, or a company would run out of money.

Its SAFE note investment document solves accounting difficulties and challenges around early-stage investment. This document has been validated by founders and investors, allowing entrepreneurs to raise money with little to no legal fees and a turnaround time of a day or two. Organizations like the American Medical Association, AdvaMed and the Consumer Technology Association have the buy-in, validation and potential to start tackling these processes. Standards could be set for protected innovation time, structured innovation positions and fellowships for organizational employees, and deal templates and best practices to shorten sales cycles and avoid onerous terms.

These problems are large, endemic and complex, but I am optimistic we can begin to work together to solve them to maximize our common interest: increasing the value of global healthcare.

In healthcare these days, ‘There’s an app for that’… unless you really need it

When a digital health company announces a new app, everyone seems to think it’s going to improve health. Not me.

Where I work, in San Francisco’s public health system, in a hospital named after the founder of Facebook, digital solutions promising to improve health feel far away.

The patients and providers in our public delivery system are deeply familiar with the real-world barriers to leveraging technology to improve health. Our patients are low-income (nearly all of them receive public insurance) and diverse (more than 140 languages are spoken). Many of them manage multiple chronic conditions. The providers that care for them struggle with fragmented health records and outdated methods of communication, like faxes and pagers.

So when companies tell us they will cure diseases, drive down costs, and save lives with state-of-the-art technology, I am often hesitant. 

More than thirty billion dollars have been invested in digital health since 2011. The resulting technological innovations, such as mobile applications, telemedicine, and wearables, promise to help patients fight diabetes, treat chronic disease, or lose weight, for example.

However, we have yet to see digital health drive meaningful improvements in health outcomes and reductions in health expenditures. This lack of impact is because digital health companies build products that often don’t reach beyond the “worried well” – primarily healthy people who make up a small proportion of health expenditures and are already engaged in the healthcare system.

If we’re designing health apps for those who already have access to healthcare, nutritious food, clean air to breathe, and stable housing, we’re missing the point.

It’s no surprise that health apps are incongruous with the needs of low-income, diverse, and vulnerable patients when these populations are unlikely to be a part of user testing. In addition, the science that technology developers draw from is generated by clinical trials conducted on participants who often do not reflect the diversity of the United States.

Over 80% of clinical trial participants are white, and many are young and male. Women, racial and ethnic minorities, as well as older adults must be included in clinical trials to ensure the results — drawn on not only for product development but also for clinical care and policy — are relevant for diverse populations. 

Research conducted by my colleagues at the UCSF Center for Vulnerable Populations demonstrates that patients who are low-income are unable to access many digital health apps. One of our patients testing a popular depression-management app said, “I’d get really impatient with this” and expressed concern that “Somebody that’s not too educated would be like, ‘now, what do I do here?’” A caregiver testing a different app also voiced frustration, saying “Yeah, it’s an app that makes you feel like an idiot.” Yet, despite these barriers, the majority of our study participants (most of whom have smart phones) also express a high interest in using technology to manage their health.

 While the private sector is great for innovation, it will fail to improve health in a meaningful way without real-world evidence generated in partnership with diverse patients. In addition, these for-profit companies face long odds to benefit their shareholders in a substantial way without learning how to reach the 75 million patients on Medicaid (including 1 in 3 Californians) who stand to benefit from digital health solutions.

 There’s an answer, though, and it’s within reach. To truly improve health outcomes, digital health companies must partner with public health experts and patients to not only ground themselves in evidence-based research, but also build products that meet the needs of all patients. 

Along with the compelling business potential of innovating for Medicaid, infrastructure to support this work is growing. For example, organizations like HealthTech4Medicaid are bending the arc of innovation towards the patients who need it most through advocacy and key partnerships with payers, policy makers, care providers, and technology developers.

To truly revolutionize health, let’s demand that technology creators and scalers include diverse end users early and often. Otherwise, the app “for that” will be for them, not for all of us.