By: Larry Dobrow

You may or may not be familiar with Dr. Bishal Gyawali, known to his 4,900 or so Twitter followers as @Oncology_BG. A Nepali-born oncologist trained in Japan who’s currently a research fellow in the department of medicine at Brigham and Women’s Hospital, Harvard Medical School, Gyawali has a résumé that seems almost impossible for a 31-year-old. Among other pursuits, he serves as an editorial adviser to the British Medical Journal and has worked with the U.K.’s Institute of Cancer Policy and the Belgium-based Anticancer Fund.

Gyawali’s professional credentials might be key opinion leader (KOL) manna, but the way he wields the influence that comes with them is atypical. He’s active on Twitter, where he casts a skeptical, thoughtful eye on everything from highly technical oncology research to bigger-picture systemic issues.

“He has become a respected authority on global access issues and oncology treatment in low- and middle-income countries, and not just on Twitter or social media,” says Dr. H. Jack West, founder and president of the nonprofit cancer-education organization Cancer Grace and web editor for JAMA Oncology. “He’s young and didn’t come out of a training program that’s usually a feeder to international renown. There are ways to carve out your own place that didn’t exist even five or six years ago.”

Welcome to the era in which anyone can be a healthcare influencer. “We’re moving from three or four or five Ps — provider, payer, patient — to one: ‘people,’” says Sara Holoubek, CEO of strategy and innovation consultancy Luminary Labs. “As we move to a model where patients are empowered — where they have computer-grade devices such as smartphones and smartwatches that do some of the things you used to have to go to the doctor for — people are leading the charge.”

It’s a reality to which traditional health and media influencers are slowly accustoming themselves. It’s also one that seems alternately to dismay and confuse many of those same A-listers.


Social media gives new influencers a voice

The old guard may not have sought to exclude new and different voices from the conversation, but there was no obvious entry point for them in the pre-social media era. For better or worse, influence was largely defined by professional credentials.

“The high-profile media was very attuned to using these KOLs as their go-to voices,” says GCI Health CEO Wendy Lund. That effect, she notes, was amplified by other personal and professional associations. “Working with pharmaceutical companies allowed many of them to build their followings even more. And the institutions they came from — Johns Hopkins, Memorial Sloan Kettering, MD Anderson Cancer Center — did a great job building them up.”

Along those lines, “going viral” wasn’t yet a thing during the reign of the KOL. “There was a significant hegemony that exercised its power and control over the conversation,” says John Nosta, president of innovation think tank Nostalab and a member of the Google Health Advisory Board. “The industrial-academic complex controlled the story. People found validation of their ideas in that echo chamber.”

Gyawali himself is keenly attuned to fundamental shifts in the nature of influence in healthcare. “Ten years ago, only a few selected people working at topmost organizations — the so-called ‘big names’ — would control the direction of healthcare,” he explains. “However, with social media, independent, thoughtful voices got a platform to be heard.”


You gotta know what you’re talking about

However, clever use of social media hasn’t by itself elevated the influence of these voices. “They came from someone who was not a big name and, hence, was also aloof from the conflicts of interest that big names usually have,” Gyawali continues. “They had no big stakes in the game, so to speak, so they could be bold and courageous enough to call a spade a spade, because ultimately it was only the patient outcomes that mattered.”

Indeed, influence has evolved to include aspects of voice. But this has not changed one fundamental tenet of influence: You gotta know what you’re talking about. Jane Sarasohn-Kahn, a health economist who founded the consultancy Think-Health and writes for The Huffington Post and her own HealthPopuli site, is heartened by the turn back toward “trusted nodes” where scientific fact reigns supreme.

She recalls a recent lunch with the head of Italy’s minister of health. “There are algorithms in social media in Italy misinforming people about vaccines. So now you’ve got what amounts to the head of Italy’s NIH tweeting pro-vaccine messages, which can’t be a bad thing,” she explains. “In healthcare at least, we still live in a fact-based world.”

The worry, of course, is that healthcare influence could splinter in a manner similar to the way political influence has splintered. “More [influencers] is better. The problem is that more isn’t necessarily smarter,” Nosta says. “In health and not in health, we’re seeing the emergence of influence that is incorrect, ignorant, and dangerous. Look at vaccines and autism, where both scientific and social fraud have been perpetuated upon humanity.”

And then there’s concern about pharma, always the last in line when it comes to embracing innovation in the realms of marketing or communication.

That’s why Holoubek was so encouraged by Sanofi’s response when Roseanne Barr more or less blamed Ambien for racist comments she tweeted. A few hours after Barr made the claims, the drugmaker responded in a tweet from its Sanofi U.S. handle: “People of all races, religions, and nationalities work at Sanofi every day to improve the lives of people around the world. While all pharmaceutical treatments have side effects, racism is not a known side effect of any Sanofi medication.”

“It’s what any other brand in any other industry would have done, and it reflected so positively on the brand and on the company,” Holoubek says. “Ten years ago, a pharma company would have ignored [Barr’s mea culpa] or maybe a month later issued a very formal statement. So maybe pharma and healthcare are learning how to dance that tango.”

Given the importance of the social media platforms upon which the new breed of influencers conduct their conversations and air their concerns, it’s no surprise those companies have pressed forward with formal health units. “Organizations used to live in their bubbles, but they’ve gotten smart and are embracing partnerships with unexpected partners. Tech companies have incredible data and the reach to do this,” Lund says. Asked if she considers those companies to be the proverbial elephants in the room, she responds, “I see them as the intrigue in the room.”


Here comes Amazon

Which leads us to the feverish speculation about Amazon’s eventual place in the health-influencer ecosystem. When the company announced its joint venture with Berkshire Hathaway and JP Morgan, its influence was felt in the form of immediate plunges in the market value of pharmacy benefit managers, or PBMs, (Express Scripts, CVS Health) and insurers (Aetna, Anthem) alike.

Nearly a year after the announcement, few specifics have been presented, but it almost doesn’t matter. Amazon announced the purchase of online pharmacy PillPack in June, pharmacy and drug distributor stocks followed the same pattern of as PBMs and insurers. The day news of the deal became public, CVS Health, Rite Aid, and Walgreens collectively shed $12.8 billion in market value.

“[Amazon] has the muscle to make anything from a speculative concept into a reality,” West says. “For insurance, this could be the equivalent of going from place-based phones to person-based phones.”

It doesn’t hurt that Amazon enjoys a degree of awareness matched by few companies in the history of humankind. “Amazon and healthcare — that’s the kind of thing that will stick to the roof of consumers’ brains,” Nosta says.

However, when asked to predict the healthcare influencers of 2023, even the most ardent futurists hedge. “Five years ago, we did not see Amazon becoming a player in this space,” Holoubek notes. “Factor in that sometime in the next five years we’re definitely going to have a recession, and it’s pretty much impossible to say who the influencers will be.”

West agrees. “We’re like dinosaurs with an ice age coming. Lots of ill-prepared dinosaurs are going to go extinct,” he says. “Healthcare is so staggeringly inefficient right now that there is too much opportunity to do things better. But I don’t think anyone knows how that will affect influence.”

Nosta ventures a prediction of sorts. “I’m not gonna tell you who [the influencers of 2023] will be, but I’ll give you the initials: A.I.,” he quips. “The volume, source, speed, and veracity of data is increasingly beyond our ability as humans to assimilate. As terrifying as it might sound, the arbiter of information will be technology itself.”

Gyawali, on the other hand, speaks hopefully about the continued rise of individuals not formally associated with legacy organizations. “I’d hope the influence of big journals would dwindle because of the [rise of] open-access journals and preprints and social media. Independent, conflict-free, thoughtful voices will continue to have the most influence.”