Camille Castelyn and Marisa Dallas
Keywords: ai, pharmaceutical industry, pharmacy, bias, clinical trials, data, bioethics
Camille Castelyn 0:04
Hello, and welcome to voices in bioethics podcast. I’m your host, Camille Castelyn, and today we have the great pleasure of having Marisa Dallas on the podcast with us. Welcome, Marisa.
Marisa Dallas 0:16
Thanks Camille.
Camille Castelyn 00:17
So Marisa, you have a Bachelor’s of Science in Human Biology, and you’re also an alumna of the Bioethics Master’s in Bioethics program. How did you like the program and the people that you met in the program? How was that experience for you?
Marisa Dallas 00:34
Honestly, it was a wonderful experience, it was probably my favorite degree that I’ve completed out of three so far. It was really a pleasure. Honestly, everybody I met in the program was super helpful, very nice. All the professors were world class and always willing to hop on a call or answer emails about any clarification I had or further discussion I wanted to do. I’m still in contact with many of the people that were in my cohort, which has been great just for networking, and also just friendships, so it was a great, wonderful experience all in all.
Camille Castelyn 01:07
Yeah, that’s awesome. That’s great. I have to say, that was my experience as well.
Marisa Dallas 01:11
And I met you in the program, Camille.
Camille Castelyn 01:14
Oh, yeah. Yeah, I mean, I think we started in the same year as well, which is a while back, right.
Marisa Dallas 01:21
Yeah, yeah. A couple years ago now.
Camille Castelyn 01:24
Yeah, it was that in 2018. Did you also start then, or bit later?
Marisa Dallas 01:29
I started in 2019.
Camille Castelyn 01:31
2019. Okay, yeah, I’m not sure about me, either. But one, either 2018 or 19? Yeah. And then you went on to do a super interesting thesis project. Your thesis title was, “Sex-based Bias in Healthcare Artificial Intelligence Algorithms: What is it? Where does it come from? And How Do We Mitigate It?” I mean, talk about a hot topic. So how was that for you? And tell us more about what were your findings? And yeah, the responses that you guys got as well? Are you planning to publish it?
Marisa Dallas 02:07
Yeah, definitely. So yeah, I’m hoping to publish, I just have to polish a couple more things on it first, but yeah, basically, I was just looking at how artificial intelligence algorithms are being used more and more in the healthcare space to triage patients to allocate resources, etc. It’s becoming like a kind of, I guess, quote-unquote, cheaper and easier way to do those things. But one of the issues with them is the data they’re trained on is mostly male data, because that’s oftentimes who signs up for clinical trials the most. And there’s a lot of data lacking, especially in women of childbearing age, because it’s kind of difficult to subject to a woman who could become pregnant to something that you don’t know what would happen to her unborn child. So it’s, it’s an interesting space. There definitely needs to be more women representation in clinical trials to help mitigate some of these issues that we’re seeing. And so the healthcare artificial intelligence algorithms can be trained on both male and female data, so we can get more accurate results from them. So yeah, it’s definitely an emerging issue in the ethics space and kind of the healthcare space in general as well.
Camille Castelyn 03:24
Yeah, that sounds awesome. Well, very important work when you put it like that. There was like a very good documentary as well about the bias in algorithms, but I can’t remember what it’s called right now.
Marisa Dallas 03:37
You have to send it to me once you think of it.
Camille Castelyn 03:39
Yeah, sure. I’m sure you’re well read on the topic as well. And was there a reason that you specifically chose like the sex-based bias? Because I know like, there are a lot of racial biases as well to name a few.
Marisa Dallas 03:54
Yeah, so I was interested in doing something in the artificial intelligence space after I took the artificial intelligence ethics course with Dr. Silberman at Columbia. As I got to more reading, just learning more about the issues in artificial intelligence. And like you said, there’s a lot of various issues going on with the algorithm. I kind of went towards the sex-based bias, just because it’s an important issue right now. and I guess I could kind of relate to it more being a female myself. S it was really interesting to read about it and just kind of see the reasoning behind why there’s a lack of female representation in clinical data, and also just kind of the steps that we could take in the future in order to help mitigate these issues from happening.
Camille Castelyn 04:42
Yeah, for sure. And what do you think are some of the steps that we should be taking to mitigate those issues, the issues of sex-based bias intelligence algorithms?
Marisa Dallas 04:53
Yeah, definitely. I think one of the main steps that we can take is to enroll more women in clinical trials there Spend some incentives through advertising, the clinical trials at nail salons, grocery stores, hair salons, places that are more female, there’s like more females that go to, if that makes sense. So just to try to get the word out more, part of the reason why there’s not as much female enrollment in these trials is one, a lot of women don’t know about them. And two, it’s harder for women to get away from their responsibilities in the home in order to participate in a clinical trial. When you’re working a full-time job and you have a family, it’s kind of hard to take, you know, a couple hours out during the week in order to go participate. So hopefully, we’ll be able to increase enrollment so we can have that data for the algorithms in order to help mitigate some of the bias that’s happening with these programs.
Camille Castelyn 05:51
Yeah, for sure. I mean, that’s definitely some of the common issues that faced women and people who are caretakers and having to take on those roles additional to all the other roles that the world expects of us. So yeah, that makes sense. In your title, you also say, “Where does it come from?” So would you just say that it’s society’s biases that are just being expressed? Yeah. I mean, if we think about the whole scandal of all these AI apps that are also creating these avatars, and how people have been up in arms about how they are giving more sexualized images to women as well, because they’re scouring the internet for data, right? I don’t know if you saw that.
Marisa Dallas 06:38
Yeah. Are you talking about like the Facebook Metaverse stuff?
Camille Castelyn 06:42
Yeah. There’s been like in the news, there’s been as well, one of the apps, it’s called Lanza. And it generates those avatars of people you upload, like 10 or 20 selfies, and then it generates completely, like unique avatars of you. But then there’s been, like a woman was of Asian descent, and she got a lot of just sexualized images. Whereas if you’re a male, you get a lot of just more interesting and different, like you be an astronaut, or you would be depicted as a traveling in into forest space or something like that. But I can send you the link later, as all and you can check it out. Let us know what you think. Yeah.
Marisa Dallas 07:24
Yeah, that’s really interesting. I didn’t know about that. I’d seen some things online about how in the Facebook Metaverse, people were complaining that there was like a lot of overly sexual tones to it, that they felt were inappropriate, especially for children to be viewing.
Camille Castelyn 07:40
Yeah, I think that’s the thing like these apps are just they’re popping up and take knowledge. They’re developing them and there’s no like, control or yeah, regulation of it at this moment in time, at least.
Marisa Dallas 07:53
I agree. I think that’s one of the issues right now in the technology space is that the technology is evolving more rapidly than the laws associated with it are. I think we saw that really come to head with the whole Facebook trial with the Senate, of how it seems that the government officials that were quote unquote, trying Facebook were kind of out of touch with what was going on in the technology space. So it’s kind of hard to create legislation for something that you don’t really understand, which is understandable. And especially with the rate technology evolves, it’s hard to keep up with it, with how slow our legal system moves.
Camille Castelyn 08:32
Yeah, for sure. Luckily, we have a few other bioethicists, as well working on the legal aspects of it. And so Marisa, you then finished your Master’s in Bioethics at Columbia University. And then you chose to do a Doctorate of Pharmacy at the University of Michigan, which are currently busy with. And I find that so interesting, because not a lot of I think the people who complete the program in bioethics choose to go into the pharmaceutical industry just because of the image that is out there, which is often like a bad image about pharma being notorious for being unethical. So I think that’s very unique and interesting. So yeah, tell us more about why did you choose that path?
Marisa Dallas 09:25
Thank you. Yeah, definitely. So I actually became interested in pharmacy while I was doing my Masters at Columbia. I did a concentration in biotechnology and pharmaceutics and ethics. So I took a few classes about pharmaceutical development and like I mentioned earlier, the AI ethics, and really became interested in pharmacy through that and so I was lucky enough to be able to continue my education at the University of Michigan to get my doctor of pharmacy. And it’s been a really great experience so far. I am only in like my P 1.5 year So I’m not too far into the program, but it’s really been great.
Camille Castelyn 10:04
That’s great. Yeah, I know, like, when we spoke, you were very interested like in the non-compliance, often that we find, with patients using pharmacy drugs, and then struggling to comply with all the regulations or prescriptions, etc.
Marisa Dallas 10:24
Yeah, that’s definitely an ethical issue in pharmacy, the non-adherence is really difficult, especially when, for example, if someone has diabetes, that they’re choosing not to use insulin for, they know there’s all these issues that they’re going to be facing in the future due to their non-compliance. But at the end of the day, they still have the autonomy to decide whether or not they want to take their medication. But from a healthcare provider standpoint, it can be really frustrating, because you just want to kind of tell them, like, why aren’t you doing this, you know, but all you can really do is just explain what the benefits of using the medication are, what the long-term consequences of not using it are, and then hopefully, they’ll become compliant from there. But unfortunately, you do see a lot of people that have preventable issues due to non-compliance of their medication. And then I guess another issue in pharmacy is kind of like the personal bias aspect, especially with hot button issues regarding like abortion and birth control and things like that. I don’t think there’s a lot of them, but there are some who choose not to dispense Plan B or birth control due to personal beliefs that they have. So that’s another interesting ethical issue as to whether or not healthcare providers should be allowed to, I guess it’s withholding care in a way right, to not dispense birth control or plan B, like things related to reproductive health, based off of like, personal bias that they might have.
Camille Castelyn 11:57
Yeah. And how do you think you’d approach something like that?
Marisa Dallas 12:01
Yeah, that’s a really interesting question. I know, we did talk about it. When I was in master’s program at Columbia. It’s hard when you’re approaching these intersectional issues that might be related to religion, or culture or something like that. So you don’t want to prevent somebody who might be under pressure in every other way. But their religion prevents them from dispensing birth control or plan B. I think, as of now, you can obtain your prescription at a different pharmacy than that also calls into question like if you’re living in a rural versus an urban area, or is obviously in an urban area, you’re going to have a lot more options of places you could go. If particular pharmacist or physician won’t give you a birth control prescription, you could just go to another pharmacy. Whereas if you’re living in a rural area where maybe there’s only one pharmacy within 30 minutes of you, and they won’t dispense the birth control, it’s a bit trickier. But I think now with the emergence of like the mail order birth control, where you can like order it online, and have it sent directly to your house, it’s kind of helping with a lot of those issues.
Camille Castelyn 13:10
Yeah, yeah. Oh, definitely an important topic as well. And very relevant after all the things that happened this year. And yeah, if you say that your non-adherence is kind of one of the issues that you’re interested in, was it based on any personal experience or something that you had with someone that you knew who didn’t comply with their medications? I know you, you mentioned that your dad is a doctor and your mom is a biochemist? Or is it just a more general interest in it?
Marisa Dallas 13:40
Yeah, that’s a good question. Thank you for asking. Actually, it was kind of from when I started working at my dad’s clinic, when I was younger, and I worked there for about 10 years now on and off, you know, just kind of hard seeing people that weren’t complying with treatment, and then they were getting way worse later on. And you knew it was preventable if they had just stuck to their treatment plan. And it’s really frustrating to see. But then the day like I said, it’s people have the autonomy to decide whether or not they want to adhere to their treatment. And yeah, all you can really do is just give them all the facts of what will happen if they don’t adhere and kind of give them the treatment plan. And I guess from there, the patient just has to decide what they want to do. And I understand it’s deeper than someone just deciding they don’t want to comply. A lot of it has to do with maybe not being able to afford medication. Insurance can be difficult to deal with and they might not be covering the medication that someone needs. Or maybe the person can only afford a co-pay for half the dose so they’re supposed to be taking. So some of the time instead of them just not taking the drug in general you see them taking like a lower dose or maybe like skipping every other day, just to kind of stretch out the pills that they have because unfortunately cost can become an issue. So I know that a lot of the pharmaceutical companies have programs that you can sign up for where they’ll help pay for the medication that you have. And there’s various government programs that you can get involved with as well. But I think another issue is a lot of people don’t really know about these programs. And so maybe at the healthcare practitioner level, if we are trained, I know at University of Michigan, they do a really good job of showing us how to access resources to pass along to our patients who might be dealing with some financial difficulties. And I think that’s really great. Because that way we can get the word out more about these programs that people can use in order to help them if they’re in a hard spot.
Camille Castelyn 15:46
Yeah, I think that’s great. So there might be a few reasons why for noncompliance, including insurance and misinformation, financial difficulties, bit of education as well. And then, of course, also, as you say, like it is anyone’s personal choice as well, how they choose to deal and to treat their diagnosis. I wonder what did you say about if we think of just like the paternalistic view of doctor-patient relationship? Do you think there’s like a similar relationship when it comes to people being prescribed medication like the pharmacist? Or do you think that at the moment that’s kind of bypassed? It’s not really your role? Or it is?
Marisa Dallas 16:29
Yeah, that’s a really interesting point that you bring up. And actually, it’s funny, because when I started the Master’s in Bioethics program at Columbia, I think I really had like a paternalistic view of medicine, where I like, you just thought I was kind of like, well, if the doctor tells you to do it, like, why don’t you just do it? But as I went through the program, and learned more about all the contributing factors to these issues, then you start to think, Okay, well, you know, at the end of the day, people have their own rights and their own autonomy to decide whether or not they want to do something. But I think it’s interesting, because medicine, you know, if we look at maybe 50 years ago, it was very paternalistic. You know, doctors were kind of treated like gods in a way, and you never got a second opinion. You went to the doctor, whatever the doctor told you to do, that was just kind of like the gospel, right. But nowadays, there’s so many more doctors, there’s more access to doctors through telehealth and phone appointments, and things like that, that it’s really easy to get an opinion from one doctor or go to another doctor for a second opinion. And kind of like weigh out what you want to do based off of your own research. The internet has made a lot of things really accessible for people to read up on. And there’s a lot of really good health literacy, things on the internet that kind of break down different diseases and medications in an easy-to-understand way for someone who maybe isn’t in the medical field.
Camille Castelyn 17:56
What’s an example of one of those resources? Maybe for listeners would be interested in checking it out?
Marisa Dallas 18:02
Yeah, definitely. So one of the really interesting resources is you can pretty much Google any drug. And then just Google like, for example, like Enbrel, FDA leaflet, or something like that. And you can pull up the exact FDA leaflet that tells you what the drug has been approved for how the drug works, what the ingredients are in the drug, in a pretty like, simple to understand way and directly from the FDA. So it’s accurate information. And yeah, it’s interesting, you can just Google and read up on your medications that you’re taking, or maybe a loved one is starting a new medication that you want to learn more about. So it’s really interesting. It’s a great resource to have.
Camille Castelyn 18:48
Yeah, I think that’s so important for people to also take responsibility for the way that they take their medications. It’s a whole system, including the doctor and the pharmacist, and if there are caretakers involved in whatever, but just to be informed about the medications that you’re taking. And I think doctors don’t always have the time, or they don’t take the time to really just talk about the side effects or how it might impact you or not impact you. And I’ve had a few experiences like that. I don’t know, my body is very sensitive and stuff. So if there’s like a 1% chance that you’re gonna get this horrible side effect, it’s probably me that it will happen to and yeah, I’ve kind of been bummed a lot of times that doctors haven’t told me, “Look, this is one of the things that you should look out for.” But then if you start reading up and you inform yourself, and you’re like, oh, okay, that makes sense. That’s why I’m feeling the way that I am. So it’s good to have these resources and to be informed and I think that’s an important role of the pharmacist as well. Could be to also just help that whole process.
Marisa Dallas 19:58
Yeah, exactly. Yeah. One of the things that we learned how to do in school is how to counsel patients on medications that they’re taking. Because like you said, oftentimes, the physician is so busy, they have a lot on their plate. So it’s difficult for them to kind of run through the medication with a patient as well, especially having the pharmacist as a resource who goes through four years of schooling, just learning about drugs and drug interactions and things like that. Yeah, and I agree with you, I think it’s really important for people to take charge of their own health and be informed. And I think if you’re more informed about the things that could happen down the line, you’ll be more proactive about your health, maybe a bit more preventative, which I’ve done in the day is going to help a lot. I mean, what is the saying? It’s like an ounce of prevention is worth a pound of cure, right?
Camille Castelyn 20:47
Yeah, yeah. So true. Then one of the last questions that I want to ask you is, after the pandemic, we’ve seen an uprise in telehealth, and I’m curious about how it works in the US, because you’re in South Africa, like, it’s been great that we’ve had a lot of telehealth options being given to, to people who can’t necessarily come to the doctor, so they’d maybe even be on WhatsApp, speaking to a doctor if they’re in a rural community that don’t have transport or something like that. And then they might get prescribed a drug or whatever. But I worry about that sometimes. Because, yeah, then you have the prescription to get the medicine. But then always I am curious to know how if people really know what they’re doing, or even if you get a repeat of a script, without actually seeing a doctor. But I guess in the US there definitely be a few more fail safes in built in. You think that’s an issue or space where pharmacists can play a role?
Marisa Dallas 21:52
Yeah, it’s been really interesting seeing the rise of the telehealth. In school, they’ve actually been training us a lot more in the telehealth space just because it’s such an emerging field. And pharmacists are kind of pivoting their role into more of a virtual console and a lot of pharmacies. And like you said, I think it does really increase access to health care for a lot of people that are in rural communities, or maybe are homebound or can’t really find a ride to the doctor, etc. So it really brings access to them. And like you said, you don’t even have to be on Zoom, you can just be on a phone call with the doctor and describe your symptoms. So it’s, it’s really helpful. I’ve had some telehealth visits myself with my physician. And it was pretty interesting. It’s kind of weird, right? You’re used to going into the office, and now you’re just kind of talking to somebody on Zoom and telling them what’s going on. But it’s definitely an interesting space in healthcare that I think is growing a lot. And like you said, I mean, it’s not a perfect system, I think being in person is definitely better than being on Zoom. Also, just from like having that patient provider connection standpoint in person is a lot easier to make and over call or like on a video chat or something like that. But I think like you said in the post pandemic world, we’re just kind of trying to find solutions to problems that maybe didn’t really exist before or were there but we didn’t really look at as much as we do now. So I think it’s a great option to have. It’s been interesting, because there has been some cases where when the United States people were getting, for example, Adderall prescriptions from doctors via telehealth that weren’t in their state. So for example, maybe I was getting like a prescription for Adderall from a doctor in Florida and I live here in Michigan. So then when you go to the pharmacy, and you present this prescription from a doctor in Florida, and they look at your Michigan driver’s license and your Michigan address, and they’re like, “Okay, this is kind of questionable”, that you might be denied a prescription at some pharmacies based off of them questioning the legitimacy of your prescription. So I think there, you know, there’s been some demonstration of it being abused, but I think overall, the pros do far outweigh the cons with telehealth.
Camille Castelyn 24:15
Yeah. Yeah, that’s very true as well. Are there any other challenges that you would say ethical challenges that the pharma industry or pharmacists are facing at the moment that we didn’t touch on?
Marisa Dallas 24:30
I think what you said earlier, about kind of pharma, the pharmaceutical industry, being the dark side, is still a bias that a lot of people have and I hope in the future, people see that big pharma isn’t out to just make a bunch of money and doesn’t really care about anybody. At the end of the day the pharmaceutical industry is the one that’s innovating products that are saving, you know, thousands of lives across the world and a lot of the R&D is happening in the United States, which is really great. And also with the emergence of biosimilars and more commonly generic products, which save people a lot of money, yeah, I think if people just focus maybe more on the positives of the pharmaceutical industry and the help that its providing and the innovation and medical care that just would not be there without the research and development that’s going on in that space, if that makes sense.
Camille Castelyn 25:28
Yeah, no, it does. Yeah, I think it’s good. It’s, they’re lucky to have you on their side. So and hopefully, you can also make a big impact and a change.
Marisa Dallas 25:39
Yeah, hopefully.
Camille Castelyn 25:40
Yeah.
Marisa Dallas 25:42
Yeah. And I think definitely using my Bioethics Master’s at Columbia, it’s really trained me to look at things through a different lens and consider factors that I wouldn’t have considered otherwise if I hadn’t done the program. So I think anybody that’s listening right now who’s considering a career in healthcare or law, to really consider doing a Bioethics Master’s. I think it’ll definitely enrich your education a lot, especially if you’re looking at working for maybe an IRB or getting involved with clinical trials or something like that.
Camille Castelyn 26:13
Yeah, absolutely. Thank you for offering that to our listeners. I just have one last question. What is a biosimilar? I didn’t know the word. What’s the difference between a biosimilar and a generic medicine?
Marisa Dallas 26:26
Biosimilars are basically generic products. So you have like your reference drug, which is the drug that’s developed by the pharmaceutical company comes to market, you know, they have a patent on it, that usually is about like 10 to 30 years, depending on how they structure their patent. And then once the patent expires, generics can come to market which are deemed by the FDA to be not clinically different from the reference. So I don’t want to say they’re the same thing. But essentially, it’s the same thing. So then the generic comes to market, which is often way cheaper than the reference drug. And so it kind of improves access for people because they can have a cheaper product that’s doing effectively the same thing as the reference drug is.
Camille Castelyn 27:18
Yeah. And the biosimilar?
Marisa Dallas 27:22
The biosimilars are basically just generics.
Camille Castelyn 27:25
Okay, the same thing. Okay. That’s great.
Marisa Dallas 27:29
So they can either be sold by the same company that made the reference or they can be made by a completely different company that just goes through the testing and approval process with the FDA.
Camille Castelyn 27:40
Yeah. No, that’s very interesting. Yeah. Is there anything else that you wanted to share with our listeners today?
Marisa Dallas 27:49
Ah, no I don’t, but I really appreciate you having me on the podcast. It’s been, it’s been lovely, an absolute pleasure to speak with you today.
Camille Castelyn 27:57
Yeah, thank you so much for sharing your experiences and your great knowledge on sex-based biases in AI as well as all the ethical challenges in the pharmaceutical industry. And we wish you the best of luck in your future studies and once you get employed as well, thank you so much for your time, and it’s been great.
Marisa Dallas 28:18
Thanks, Camille. It’s been awesome talking to you. Okay, have a great rest of your day.
Camille Castelyn 28:21
Thanks.