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ECONOMYMONITORGlobal Wellness2024GLOBAL MARKETGlobal Wellness Economy Monitor 2024NOVEMBER 2024Copyright 2024 by the Global Wellness InstituteQuotation of,citation from,and reference to any of the data,findings,and research methodology from this report must be credited to“Global Wellness Institute,Global Wellness Economy Monitor 2024,November 2024.”For more information,please contact researchglobalwellnessinstitute.org or visit www.globalwellnessinstitute.org.Contents What Is Wellness?iWhat Is the Wellness Economy?iiResearch Methodology and ScopeiiiAt A Glance:The Global Wellness Economy in 2023iv1The Global Wellness Economy12Wellness Real Estate213Physical Activity314Mental Wellness435Workplace Wellness516Wellness Tourism597Spas718Thermal/Mineral Springs799Healthy Eating,Nutrition,&Weight Loss8710Personal Care&Beauty9511Traditional&Complementary Medicine9912Public Health,Prevention,&Personalized Medicine105Acknowledgements111Industry Research Sponsors113About the Global Wellness InstituteThe Global Wellness Institute(GWI),a 501(c)(3)non-profit organization,is considered the leading global research and educational resource for the global wellness industry and is known for introducing major industry initiatives and regional events that bring together leaders and visionaries to chart the future.GWI positively impacts global health and wellness by advocating for both public institutions and businesses that are working to help prevent disease,reduce stress,and enhance overall quality of life.Its mission is to empower wellness worldwide.www.globalwellnessinstitute.orgAbout the AuthorsGlobal Wellness Economy Monitor 2024 was prepared by Katherine Johnston,Ophelia Yeung,Tonia Callender,and Joanne Hopkins.As GWIs principal researchers,they are the team that has defined and measured the size of the global wellness economy and its sectors over the last sixteen years.Their academic and professional background is in economic analysis,international development,and public policy.Ms.Johnston,Ms.Yeung,Ms.Callender,and Ms.Hopkins received post-graduate degrees from Georgetown,Princeton,Harvard,and Johns Hopkins Universities,respectively.Together,they bring many decades of experience conducting industry research,policy analysis,and strategy development for countries,regions,industry consortia,companies,and nonprofit institutions around the world.Global Wellness Economy Monitor 2024|iWhat Is Wellness?Wellness is a modern word with ancient roots.The key tenets of wellness as both preventive and holistic can be traced back to ancient civilizations from the East(India,China)to the West(Greece,Rome).In 19th century Europe and the United States,a variety of intellectual,religious,and medical movements developed in parallel with conventional medicine.With their focus on holistic and natural approaches,self-healing,and preventive care,these movements have provided a firm foundation for wellness today.Wellness-focused and holistic modalities have gained more visibility since the 1960s/1970s under the writings and thought leadership of an informal network of U.S.physicians and thinkers(such as Halbert Dunn,Jack Travis,Don Ardell,Bill Hettler,and others).As these have evolved,proliferated,and gone mainstream,they have informed the healthy-living,self-help,self-care,fitness,nutrition,diet,and spirituality practices that have become a flourishing wellness movement in the 21st century.The Global Wellness Institute(GWI)defines wellness as:the active pursuit of activities,choices,and lifestyles that lead to a state of holistic health.There are two important aspects to this definition.First,wellness is not a passive or static state,but rather an“active pursuit”that is associated with intentions,choices,and actions as we work toward an optimal state of health and well-being.Second,wellness is linked to holistic health that is,it extends beyond physical health and incorporates many different dimensions that should work in harmony(see figure).Wellness is an individual pursuit we have self-responsibility for our own choices,behaviors,and lifestyles but it is also significantly influenced by the physical,social,and cultural environments in which we live.Research on the determinants of health indicates that environmental,socioeconomic,and lifestyle factors can account for 80-90%of our disease risks and health outcomes.Wellness is often confused with terms like health,well-being,and happiness.While there are common elements among them,wellness is distinguished by not referring to a static state of being(i.e.,being happy,in good health,or a state of well-being).Rather,wellness is associated with an active process of being aware and making choices that lead toward an outcome of optimal holistic health and well-being.PREFACESOCIALPHYSICALMENTALSPIRITUALEMOTIONALWELLNESSENVIRON-MENTALWellness Is Multidimensionalii|Global Wellness InstituteWhat Is the Wellness Economy?The Global Wellness Institute(GWI)defines the wellness economy as industries that enable consumers to incorporate wellness activities and lifestyles into their daily lives.In our definition,the wellness economy encompasses eleven varied and diverse sectors.GWI first pioneered this concept and measured the wellness economy in the 2014 Global Wellness Economy Monitor,when we estimated wellness as a$3.4 trillion industry in 2013.To our knowledge,this was the first time that wellness was defined and measured as a global industry,with underlying sector-level and country-level data.Since then,we have published updated figures on the wellness economy for 2015,2017,and 2019-2022.The overall wellness economy definition,framework,and measurement methodology have not changed over the last decide,but we have made a few key expansions:In our 2013 dataset,we only provided regional and country-level data for three sectors(wellness tourism,spas,and thermal/mineral springs).Over time,we have expanded the depth and breadth of our research,and we have provided detailed regional-and country-level data for additional sectors every time we have published the Global Wellness Economy Monitor.In our 2020 dataset,we added mental wellness as an eleventh sector in the wellness economy(previously our figures had included ten sectors).We also significantly expanded our definition and measurement of the physical activity sector(previously this sector was defined more narrowly as“fitness&mind-body”only).In our 2020 dataset,we expanded our regional-and country-level data collection to cover all eleven sectors.For the first time,this allowed us to release aggregated wellness economy figures for every country and region(rather than just at the global level).Our wellness economy framework and data are grounded in our numerous in-depth sector-level studies,starting with our first study on the global spa industry in 2008.Since then,we have conducted pioneering research on the following seven wellness sectors:spas,thermal/mineral springs,wellness tourism,workplace wellness,wellness real estate,physical activity,and mental wellness.For each of these sectors,we have created a conceptual framework to define the sector and its boundaries,and we conduct original,country-level research to estimate the market size and arrive at globally aggregated figures.To our knowledge,these are the only studies that have estimated the size of these sectors across all countries in the world,using a consistent framework.In addition to the seven wellness sectors where we have done in-depth study,we also produce original country-level and global estimates for four other sectors:personal care&beauty;healthy eating,nutrition,&weight loss;public health,prevention,&personalized medicine;and traditional&complementary medicine.For more information and GWIs most recent data and analysis for the global wellness economy,see:https:/globalwellnessinstitute.org/industry-research/.PREFACEGlobal Wellness Economy Monitor 2024|iiiResearch Methodology and ScopeThe global wellness economy and sector data presented in this report are for the years 2019,2020,2021,2022,and 2023.The definitions,conceptual frameworks,and estimation models for each of the wellness sectors are developed by the authors under the auspices of the Global Wellness Institute(GWI),consistent with the data and methodologies used in prior GWI studies over the last sixteen years.Our dataset covers the entire world(218 countries,territories,and markets).The authors have developed original,country-level data estimates for nine wellness economy sectors(spas;thermal/mineral springs;wellness tourism;workplace wellness;wellness real estate;physical activity;mental wellness;traditional&complementary medicine;and public health,prevention,&personalized medicine),based on GWIs proprietary models and databases and drawing on a wide variety of primary and secondary data sources.Figures for the other two wellness sectors(personal care&beauty,and healthy eating,nutrition,&weight loss)follow GWIs customized definitions and conceptual framework,but they are aggregated primarily from Euromonitor and other secondary sources.The analysis is based on extensive primary and secondary research conducted from January to September 2024,including literature reviews,data research,and expert interviews.Key public and private sources consulted include:Euromonitor International,World Bank,International Monetary Fund(IMF),World Health Organization(WHO),International Labour Organization(ILO),World Travel&Tourism Council(WTTC),World Tourism Organization(UNWTO),Statista,Eurostat,U.S.Bureau of Labor Statistics,U.S.National Institutes of Health,International Spa Association(ISPA),Health&Fitness Association(IHRSA),International Coaching Federation(ICF),and many other organizations.Other sources include global travel promotion and booking websites;numerous industry-specific organizations,databases,publications,and media sources(e.g.,the Global Wellness Trends Reports by the Global Wellness Summit,Spa Business Handbook,Spa Business Magazine,Club Industry,Health Club Management,etc.);and dozens of government ministries and statistical agencies in countries around the world.Additional details about our definitions and measurement methodologies are provided in the individual chapters for each of the eleven wellness economy sectors.PREFACEiv|Global Wellness InstituteThe Global Wellness Economy in 2023 The global wellness economy has grown rapidly in the aftermath of the pandemic and reached a new peak of$6.3 trillion in 2023(representing 6.03%of global GDP).The wellness economy is a major force in the global economy,larger in size than the green economy,IT,and sports.All regions have recovered from the pandemic,but North America,Europe,and Middle East-North Africa have shown the strongest resilience and growth from 2019-2023.Nine of the eleven wellness sectors have fully recovered from the pandemic,with a 2023 market size that exceeds their 2019 level(thermal/mineral springs and workplace wellness have not yet recovered).We project that the global wellness economy will grow at a robust rate of 7.3%annually from 2023-2028,a growth rate substantially higher than the projected global GDP growth(4.8cording to current IMF forecasts).As all of the eleven sectors recover from the pandemic,the wellness economy is expected to reach nearly$6.8 trillion in 2024,and march toward nearly$9.0 trillion in 2028.Global Wellness Economy Market Size and Growth Projections,2017-2028AT A GLANCEHistoricalProjectionCAGR=Compound Annual Growth RateSource:Global Wellness Institute20172018201920202021202220232024202520262027$10.0$9.0$8.0$7.0$6.0$5.0$4.0$3.0$2.0$1.00US$trillions$4.46$5.03$5.41$8.99Historical 2019-20235.9GR$4.602028$5.80$6.32Projected 2023-20287.3GRGlobal Wellness Economy Monitor 2024|vWellness Economy Sectors in 2023$232.6b$438.2b$136.8b$781.0b$1,059.7b$1,095.7bPersonal Care&Beauty$1,212.7bHealthy Eating,Nutrition,&Weight LossPhysicalActivityWellness Real EstateMental WellnessPublic Health,Prevention,&Personalized Medicine$830.2bWellness Tourism$553.0b Traditional&Complementary Medicine$51.8b$62.7bThermal/Mineral SpringsWorkplace WellnessSpasNote:Manufacturing is a value-added figure;the other sectors are a revenue or market size measurement.Tourism includes both inbound and domestic trip expenditures.Source:Global Wellness Institute,World Bank,WHO,Gartner,LSEG,Euromonitor,Global Sports Insights,IQVIA$18.0$16.0$14.0$12.0$10.0$8.0$6.0$4.0$2.00PharmaceuticalsSportsGreen EconomyITWellness EconomyHealth ExpendituresManufacturingGlobal Wellness Economy Versus Other Major IndustriesMarket Size in 2023 US$trillions$2.65$4.80$4.97$6.32$10.60$16.20$1.61$4.65Tourismvi|Global Wellness InstituteGlobal Wellness Economy Monitor 2024|15.9GR2019-2023$6.3 trillionGlobal Market In 2023Note:Numbers do not add due to overlap in sectors.Source:Global Wellness InstituteGLOBAL WELLNESS ECONOMY:$6.3 trillion in 2023Public Health,Prevention,&PersonalizedMedicine$781bPersonal Care&Beauty$1,213bSpas$137bHealthy Eating,Nutrition,&Weight Loss$1,096bWellnessReal Estate$438bWellnessTourism$830bPhysicalActivity$1,060bMentalWellness$233bSprings$63bTraditional&ComplementaryMedicine$553bWorkplaceWellness$52bCHAPTER 1 The Global Wellness EconomyDefinitionThe eleven industry sectors that enable consumers to incorporate wellness activities and lifestyles into their daily lives.2|Global Wellness InstituteThe global wellness economy has grown rapidly in the aftermath of the pandemic and reached a new peak of$6.3 trillion in 2023.While the global wellness economy was initially hit hard by the pandemic in 2020,it has rebounded quickly,fueled by the ever-expanding consumer interest in and need for wellness which has only accelerated in the wake of COVID-19.In 2023,the global wellness economy stands at$6.3 trillion dollars,over 25%higher than its size in 2019.After an 8.5%downturn in 2020,the wellness economy grew robustly by 17.5%in 2021 in its initial phase of recovery from the pandemic,and then growth tapered off to 7.2%in 2022 and 9.0%in 2023.Looking at its overall trend since before the pandemic,the global wellness economy has been increasing at an average annual rate of 5.9%from 2019-2023,a growth trend that is significantly faster than the global GDP growth rate of 4.6%.1 With its rapid post-pandemic recovery and a growth rate that has been faster than economic growth,the global wellness economy has also been growing in its share of the overall economy.In 2023,the wellness economy represented 6.03%of global GDP,as compared to only 5.75%in 2019.Global Wellness Economy Market Size and Growth Projections,2017-20281Global GDP data from:IMF,World Economic Outlook Database,April 2024 Edition,https:/www.imf.org/en/Publications/WEO/weo-database/2024/April.HistoricalProjectionCAGR=Compound Annual Growth RateSource:Global Wellness Institute20172018201920202021202220232024202520262027$10.0$9.0$8.0$7.0$6.0$5.0$4.0$3.0$2.0$1.00US$trillions$4.46$5.03$5.41$8.99Projected7.3GR$4.602028$5.80$6.32Global Wellness Economy Monitor 2024|3The wellness economy is a major force in the global economy,larger in size than the green economy,IT,and sports.Wellness has become a major force in the global economy.With its rapid growth in recent years,the global wellness economy is now larger in its market size than many other major industries,including IT,sports,and pharmaceuticals.The green industry has emerged and grown over the last few decades alongside the growth of wellness,with a similar aim of addressing some of the worlds most pressing future challenges.In spite of the rapid growth of green and sustainability businesses,the wellness economy in 2023 is more than 30%larger than the green economy(estimated at$4.8 billion in revenues in 20232).Wellness is also nearly 60%of the size of global health expenditures(estimated at$10.6 trillion in 20233).Global Wellness Economy Versus Other Major Industries Market Size in 20232Dai,L.,et al(2024).Investing in the green economy 2024:Growing in a fractured landscape.London:LSEG.https:/ estimates based on data from the WHO Global Health Expenditure Database(accessed July 24,2024).Note:Manufacturing is a value-added figure;the other sectors are a revenue or market size measurement.Tourism includes both inbound and domestic trip expenditures.Source:Global Wellness Institute,World Bank,WHO,Gartner,LSEG,Euromonitor,Global Sports Insights,IQVIA$18.0$16.0$14.0$12.0$10.0$8.0$6.0$4.0$2.00PharmaceuticalsSportsGreen EconomyITWellness EconomyHealth ExpendituresManufacturingUS$trillions$2.65$4.80$4.97$6.32$10.60$16.20$1.61$4.65Tourism4|Global Wellness InstituteAll regions have recovered from the pandemic,but North America,Europe,and Middle East-North Africa have shown the strongest resilience and growth from 2019-2023.Since the onset of the pandemic,North America has surpassed Asia-Pacific to become the largest regional wellness economy,a shift that has occurred due to prolonged pandemic effects and slower growth in some major Asian markets in 2020-2022,as well as currency depreciation in 2022 and 2023(see further discussion below).North America($2.2 trillion),Asia-Pacific($1.9 trillion),and Europe($1.7 trillion)together account for over 90%of the entire global wellness economy.Per capita spending on wellness is significantly higher in North America($5,768)and Europe($1,794)than in other regions of the world.It is important to keep in mind that some of the wellness sectors are“export industries”(i.e.,selling services to people who are not residents of the country in which the business is located).For example,about 27%of all wellness tourism expenditures are from international travel;likewise,a significant portion of revenues in thermal/mineral springs and some types of spas come from international visitors.Therefore,not all of the wellness spending shown in the table below for each region is made by residents of that region.Wellness Economy by Region,2019-2023Wellness Economy Average Annual Growth Rate(US$billions)Per Capita 20232022-20232019-20232019*2020*2021*2022*2023North America$1,574.7$1,517.1$1,776.5$2,010.9$2,158.7$5,7687.4%8.2%Asia-Pacific$1,618.4$1,497.9$1,703.0$1,705.8$1,878.3$43910.1%3.8%Europe$1,322.4$1,171.1$1,438.7$1,506.3$1,652.8$1,7949.7%5.7%Latin America-Caribbean$306.8$228.2$275.0$330.9$374.2$56313.1%5.1%Middle East-North Africa$127.4$118.6$136.1$155.9$165.2$3055.9%6.7%Sub-Saharan Africa$80.2$71.9$79.3$88.6$91.9$743.8%3.5%WORLD$5,030.0$4,604.8$5,408.6$5,798.3$6,321.2$7889.0%5.9%*2019-2022 figures have been revised since GWI released the previous version of the Wellness Economy Monitor(see box below for more details).Note:Figures may not sum to total due to rounding.Source:Global Wellness Institute,based on extensive primary research and secondary data sources.Global Wellness Economy Monitor 2024|5As of 2022,the wellness economies across all regions had fully recovered from the pandemic,and by 2023 all regions far surpassed their pre-pandemic/2019 levels.It can be challenging to compare the regional growth rates in 2020-2023 as a metric for which markets have been growing the fastest,because the growth trends during this period reflect recovery from the pandemic dip in 2020 and so regions with the greatest declines in 2019-2020 are likely to have higher growth rates in 2021-2023.A better metric for growth is to examine the extent to which each region has surpassed its pre-pandemic level(see chart below).As of 2023,North America,Europe,and Middle East-North Africa have shown the strongest resilience,recovery,and growth since before the start of the pandemic,with all three regions now exceeding their 2019 levels of spending by more than 20%.Although Asia-Pacifics wellness economy was not severely impacted in the first year of the pandemic(-7.4%in 2019-2020),it was also one of the slowest-growing regions in 2021 and 2022(other than Sub-Saharan Africa).The prolonged travel restrictions and pandemic impacts across Asia-Pacific,weakened economic conditions in China,and a more than 50%drop in tourism all led to a severe downturn in several sectors(wellness tourism,spas,thermal/mineral springs),which lasted longer than in other regions.Other sectors that are closely linked with consumer spending(healthy eating,personal care&beauty,physical activity,traditional&complementary medicine)have also been growing relatively slowly in the Asia-Pacific region,a trend that is largely due to the effects of currency depreciation in 2022 and 2023 across several major markets.(Note:see individual sector chapters for more details on regional growth trends and currency depreciation impacts in these sectors).The depreciation of the Japanese Yen has dampened the Asia-Pacific market growth and recovery when it is expressed in U.S.dollar terms(since Japan is such a large share of the overall region)when measured in Yen,the Asia-Pacific market is at 150%of its pre-pandemic level,as compared to 116%when measured in dollars.Source:Global Wellness Institute.Labels indicate the%to which the regions 2023 wellness economy exceeds its 2019(pre-pandemic)level.$2.4$2.1$1.8$1.5$1.2$0.9$0.6$0.30North AmericaAsia-PacificEuropeLatin America-CaribbeanMiddle East-North AfricaSub-Saharan AfricaSize and Recovery of the Wellness Economy by Region2019 Versus 2023US$trillions20192023$1.57$2.16$1.62$1.88$1.32$1.65$0.307$0.374$0.127$0.165$0.080$0.092137%of 2019116%of 2019125%of 2019122%of 2019130%of 2019115%of 20196|Global Wellness InstituteNine of the eleven wellness sectors have fully recovered from the pandemic,with a 2023 market size that exceeds their 2019 level.The wellness economy comprises eleven sectors,and their sizes and growth rates are presented in the table below.Seven out of the eleven wellness sectors declined in 2020 due to the pandemic.Wellness tourism,thermal/mineral springs,and spas were the sectors most negatively impacted in 2020,and these three sectors were also the slowest to recover in the subsequent years.All eleven sectors have resumed a positive growth trajectory in 2021-2023,although only nine have fully recovered to their pre-pandemic levels(see further discussion below).Personal care&beauty;healthy eating,nutrition,&weight loss;and physical activity are the largest sectors in the wellness economy;together,these three sectors account for 53%of the entire global wellness market in 2023.Wellness tourism and public health,prevention,&personalized medicine comprise the rest of the top five largest sectors.Wellness Economy by Sector,2019-2023Market Size (US$billions)Average Annual Growth Rate2019*2020*2021*2022*20232022-20232019-2023Personal Care&Beauty$1,071.9$943.7$1,081.9$1,142.1$1,212.76.2%3.1%Healthy Eating,Nutrition,&Weight Loss$912.4$949.7$1,040.7$1,062.8$1,095.73.1%4.7%Physical Activity$903.9$771.7$975.6$1,009.7$1,059.75.0%4.1%Wellness Tourism$696.6$343.0$462.5$637.2$830.230.3%4.5%Public Health,Prevention,&Personalized Medicine$443.9$633.7$727.4$736.9$781.06.0.2%Traditional&Complementary Medicine$483.0$452.1$512.2$526.2$553.05.1%3.4%Wellness Real Estate$225.2$274.0$342.0$386.6$438.213.4.1%Mental Wellness$150.0$163.1$190.4$209.7$232.610.9.6%Spas$116.3$71.9$83.9$105.8$136.829.3%4.1%Thermal/Mineral Springs$65.8$39.3$45.3$48.7$62.728.7%-1.2%Workplace Wellness$51.8$48.4$50.3$50.4$51.82.6%-0.02%Wellness Economy$5,030.0$4,604.8$5,408.6$5,798.3$6,321.29.0%5.9%*2019-2022 figures for most sectors have been revised since GWI released the previous version of the Wellness Economy Monitor(see box on Page 11 for more details).Note:Figures do not sum to total due to overlap in segments.Source:Global Wellness Institute,based on extensive primary research and secondary data sources.Global Wellness Economy Monitor 2024|7Wellness Economy Market Size by Sector 2019,2020,and 2023Wellness Economy Market Recovery by Sector 2023 Market Size As a%of 2019 Level$1.4$1.2$1.0$0.8$0.6$0.4$0.20Wellness Economy Market Size by Sector2019,2020,and 2023Personal Care&BeautyHealthy Eating,Nutrition,&Weight LossPhysical ActivityWellness TourismThermal/MineralSpringsPublic Health,Prevent.,&Pers.Medicine2019|Light Colors2023|Bold ColorsSource:Global Wellness Institute2020 Trad.&Compl.MedicineWellness Real EstateMental WellnessSpasWorkplaceWellness$1.07$1.21$0.91$1.10$0.90$1.06$0.70$0.83$0.44$0.78$0.48$0.55$0.44$0.15$0.23$0.23$0.12$0.14$0.066$0.063$0.052$0.052US$trillions20000000 %0Wellness Economy Market Recovery by Sector2023 Market Size as a%of 2019 LevelTotal Wellness Economy119.8%Global GDPPhysical ActivityWellness TourismThermal/MineralSpringsPublic Health,Prevent.,&Pers.MedicineSource:Global Wellness Institute and IMFTrad.&Compl.MedicineWellness Real EstateMental WellnessSpasWork-placeWellness125.7 23 market size as a%of 2019 level194.6%Healthy Eating,Nutrition,&Weight Loss Personal Care&Beauty175.95.00.19.27.67.24.53.1.9.4%8|Global Wellness InstituteSimply comparing the sector growth rates for 2020-2023 is not the best way to assess which sectors have been growing fastest,because the growth trends during this period reflect recovery from the pandemic dip in 2020 and so the sectors with the greatest declines in 2019-2020 are likely to have higher growth rates in 2021-2023.A better metric for growth is to look at the extent to which each sector has surpassed its pre-pandemic level(see chart above),in addition to its annual growth rate.The sectors that have shown the strongest resilience,recovery,and growth since the pandemic include:wellness real estate;public health,prevention,&personalized medicine;mental wellness;and healthy eating,nutrition,&weight loss.Below is a summary analysis of how the eleven wellness economy sectors have fared during the pandemic(note that more detailed analysis is provided in the chapters for each specific sector).Wellness sectors that have grown throughout the pandemic:Wellness real estate( 18.1%annual growth 2019-2023;now at 195%of its 2019 level)has been the fastest-growing sector in the wellness economy since before the pandemic,significantly outpacing projections and economic growth trends.COVID-19 has accelerated the growing understanding among consumers and the building industry about the critical role that external environments play in our physical and mental health and well-being.Mental wellness( 11.6%annual growth 2019-2023;now at 155%of its 2019 level)has grown strongly since 2019,as consumers desperately sought out products,services,and activities to help them cope with the immense stresses they faced during the pandemic and beyond.All types of products and services have posted strong growth in recent years:sleep solutions;sensory products and services;vitamins,supplements,and functional foods/beverages targeting brain health and energy;cannabis;self-improvement;coaching;and all kinds of meditation and mindfulness products and services.Many mental wellness activities are done at home or via tech platforms,and many products are inexpensive and/or easily purchased online,which helped to keep spending high amidst COVID disruptions.Public health,prevention,&personalized medicine( 15.2%annual growth 2019-2023;now at 176%of its 2019 level)grew by 42.8%in 2020,due to governments and healthcare systems accelerating their public health and prevention expenditures in response to the pandemic.Worldwide,public and private spending on public health/prevention has increased as a share of overall health expenditures(from 4.0%in 2019 to 6.1%in 2021-2023)and remains far above pre-pandemic levels.Healthy eating,nutrition,&weight loss( 4.7%annual growth 2019-2023;now at 120%of its 2019 level)has grown throughout the pandemic,as consumers sought out a variety of packaged foods and beverages,vitamins,and supplements that they believed would strengthen their immunity and help ward off disease.GWI cautions that the growth in this sector should not be interpreted as“consumers were eating healthier”during the pandemic,as there is scant scientific evidence and no consensus on how healthy these products actually are.In addition,the growth in some countries reflects food price inflation,rather than an actual increase in consumer purchases.Global Wellness Economy Monitor 2024|9Wellness sectors that initially shrank but have recovered from the pandemic:Physical activity( 4.1%annual growth 2019-2023;now at 117%of its 2019 level)declined by 14.6%in the first year of the pandemic,but it has rebounded quickly in 2021-2023 as people returned to their regular activities and exercise routines.Fitness was the most negatively impacted segment in 2020;while it has recovered and exceeds its pre-pandemic levels of spending,we estimate that participation rates for traditional gyms/fitness centers are still slightly down(possibly due to gym members not returning or shifting to online platforms,permanent gym closures,etc.).Mindful movement(yoga,Pilates,etc.)saw a major boost in popularity during the pandemic and has continued to grow rapidly,not only as at-home exercise,but also for stress relief and mental wellness purposes.Consumer spending on sports and active recreation has also grown steadily in recent years,although participation rates are still below their pre-pandemic levels.Supporting sectors(fitness tech,apparel/footwear,and equipment)all exceed their pre-pandemic levels,and fitness technology has been growing at an especially rapid rate.Traditional&complementary medicine(T&CM)( 3.4%annual growth 2019-2023;now at 114%of its 2019 level)initially declined by 6.4%in 2020 due to business shutdowns disrupting visits to service providers and product manufacturing/sales.The market has rebounded in 2021-2023,and the pandemic has boosted demand for T&CM,as consumers increasingly seek out ways to strengthen their immunity,and fend off sickness,and manage chronic conditions.The rapid rise of the cannabis and CBD market,as regulatory regimes have been loosening in many countries,has especially boosted the growth of this sector.Personal care&beauty( 3.1%annual growth 2019-2023;now at 113%of its 2019 level)initially shrank by 12.0%in 2020,due to pandemic-related retail disruptions and an overall decline in consumer spending.This sector has recovered quickly in 2021-2023,and it is now 13ove its pre-pandemic level.The growth of personal care&beauty from 2019-2023(3.1%annual growth)has slightly lagged the growth of overall consumer expenditures during this time period(4.4%annual growth),possibly because several major Asian markets have been affected by currency depreciation,which dampens growth rates in U.S.dollar terms.Wellness tourism( 4.5%annual growth 2019-2023;now at 119%of its 2019 level)was the wellness sector most adversely affect by COVID-19,shrinking by 50.8%in 2020.Its slow recovery was due to the travel bans and border closures around the world,which extended through the end of 2022 in some parts of Asia.Wellness tourism actually fared slightly better than overall tourism during the pandemic,with wellness trips and expenditures falling by less in 2020 and recovering at a faster rate in 2021-2022 as compared to overall tourism.Globally,wellness tourism expenditures have recovered to 119%of their 2019(pre-pandemic)level,while wellness tourism trips have grown to 111%.By comparison,the recovery rate for all tourism is 101%for expenditures and 90%for trips.Spas( 4.1%annual growth 2019-2023;now at 118%of their 2019 level)were hit hard by the early stages of the COVID-19 pandemic,with travel restrictions,business shutdowns,and stay-at-home orders leading to a 38.2%drop in revenues and a loss of over 4,700 businesses in 2020.Virtual offerings are a poor substitute for a physical presence and full immersion in spa experiences.The ongoing pandemic-related restrictions and tourism decline continued to affect many spas around the world throughout 2021 and 2022.Nevertheless,the industry has recovered steadily alongside the recovery of the tourism industry,and spas have posted strong revenue growth rates every year since 2020.As of 2023,global industry revenues have fully recovered and are at 118%of their pre-pandemic level.10|Global Wellness InstituteWellness sectors that shrank significantly during the pandemic and have not fully recovered:Workplace wellness(-0.02%annual growth 2019-2023;now at 99.9%of its 2019 level)contracted by 6.6%in 2020,as many of the traditional workplace wellness activities were curtailed during the pandemic amid business shutdowns and shift to remote work.The sector has rebounded in 2021-2023,but it is not quite back to its pre-pandemic level.The market for workplace wellness is primarily driven by underlying labor characteristics across countries,including the share of workers in permanent or wage/salary jobs versus temporary,contract,and gig jobs.As the structure of the global workforce changes,fewer workers are in jobs that have access to workplace wellness benefits.In addition,as employers shift toward more holistic approaches for employee well-being,investments in employee wellness becomes more difficult to quantify(e.g.,better air filtration,biophilic elements in workplaces,improved paid leave/benefits,flexible work schedules,changes to work culture,etc.).In addition,currency fluctuations affect our estimates of workplace wellness spending expressed in U.S.dollar terms.This is the case in Europe and Asia-Pacific,where currency depreciation against the U.S.dollar in some large markets has dampened growth and has prevented a return to pre-pandemic levels when measured in U.S dollars(e.g.,Germany,Russia,Japan,South Korea).Thermal/mineral springs(-1.2%annual growth 2019-2023;now at 95.4%of its 2019 level)fell by 40.3%in 2020.The sustained border closures,partial business shutdowns,and capacity restrictions effectively decimated business revenues across many regions in 2020-2021 and kept visitors from fully returning to springs businesses across many countries through 2022.The lack of full recovery at the global level is primarily due to the slow recovery of the thermal/mineral springs markets in China and Japan,which account for nearly half of all global revenues.The slow tourism recovery and weak economic conditions have kept Chinas market from returning to pre-pandemic levels;the Japan market has also been affected by currency depreciation against the U.S.dollar,which dampens its growth/recovery rates when measured in dollar terms.In Europe,springs businesses have been negatively impacted by the Ukraine war,energy prices,and staffing shortages.In contrast,across North America,the rest of Asia-Pacific,and Latin America,the thermal/mineral springs market has been booming;in these regions,revenues have grown at a robust 5.5%annually since 2019,and business has rebounded to 124%of pre-pandemic levels.10|Global Wellness InstituteRevisions and Updates to the Wellness Economy Sector DataThe 2019-2022 wellness economy figures that are presented in this report(for each of the eleven sectors,and for the overall wellness economy)have been revised and are slightly different from the figures presented in the previous edition of the Global Wellness Economy Monitor(released in 2023).These adjustments were made for a number of reasons,including changes in sector definitions and measurements to reflect the evolution of the wellness market,as well as revisions in the underlying data sources that are used for making GWIs estimates for certain sectors.International organizations that aggregate large,cross-country datasets(e.g.,World Bank,World Health Organization,Euromonitor,etc.)gather their data from individual country sources across dozens of countries.Since every country has its own release schedule for different streams of data,the data aggregators will retroactively revise their cross-country datasets and estimates,as new and updated data become available in individual countries.This is a common and expected practice among data aggregators,and GWIs updates reflect this process,as well as our own revisions as better data become available in some of the countries and segments that we analyze.During the pandemic,public sector data collection efforts were temporarily stalled or delayed in most countries,and so data availability for the years 2020 onwards has continued to improve,and the retroactive revisions have been more substantial for some sectors than they typically would be(e.g.,for country-level health expenditures,public health spending,and construction spending,among others).In this report,we present figures for 2019,2020,2021,2022,and 2023.All data revisions and adjustments have been made across all years as necessary,in order to provide a consistent time series for all sectors.Global Wellness Economy Monitor 2024|1112|Global Wellness InstituteWhat are the macro factors underlying the development of the global wellness economy?The growth of the wellness economy is underpinned by broader global economic trends as well as underlying macro factors and regional developments.Prior to the pandemic,the global wellness economy(and most wellness sectors)had been growing faster than global GDP for several years.In 2020 the global wellness economy contracted by more than three times as much global GDP.Many wellness sectors were affected more negatively than other industries during the pandemic because of their heavy reliance on tourism and in-person services.Also,many consumers see their wellness-related purchases as“discretionary”or as“luxuries,”and these kinds of expenditures are the first to be cut in times of crisis or downturn.After the initial pandemic year,recovery has been steady but uneven across regions and wellness sectors.The wellness economy grew by 11.1%annually from 2020-2023,a rate that far outpaced GDP growth(7.1%annually4)during this time period.As of 2023,the global wellness economy is 26%larger than it was prior to the pandemic.At$6.3 trillion,it has grown to 6.03%of global GDP,as compared only 5.75%in 2019.While the wellness industry has performed better than the overall global economy in the post-pandemic period,its developments reflect many overarching consumer,macroeconomic,and socio/geopolitical factors around the world.While wellness was a rising consumer value around the world prior to 2020,the pandemic has given it a significant boost to become a dominant position in the consumer wallet.Survey after survey has shown that wellness has become a priority across all regions of the world.Increasingly,consumers no longer view wellness spending as a luxury or discretionary,but as essential to maintaining good health,strengthening immunity,increasing longevity,and improving mental resilience.This is a key reason for the strong performance of the global wellness economy as compared to overall economic growth.Different regions around the world have witnessed divergent paths to recovery from the pandemic,and their growth trends continued to vary in 2023.While the global economy grew by 4.1%from in 2023(in nominal US$),the Middle East and Central Asia shrank by 1.5%,emerging and developing Asia grew modestly by 0.7%,the Latin America-Caribbean economies expanded by 12.2%,the European Union 4All global and country-level GDP data in this section are from:IMF,World Economic Outlook Database,April 2024 Edition,https:/www.imf.org/en/Publications/WEO/weo-database/2024/April.Global Wellness EconomyGlobal GDP15%5%0-5%-10 19-20202017-20192020-2023Average Annual Growth:Wellness Economy Versus Global GDPSource:Global Wellness Institute and IMF.Labels indicate the%to which the 2023 wellness economy and global economy exceed their 2019(pre-pandemic)levels.6.2%-8.5.1%-2.6%3.8%7.10%of 2019126%of 2019Global Wellness Economy Monitor 2024|13rose by 9.4%,and the U.S.economy grew by 6.3%.These differences are reflected in consumer spending and the growth rates of different wellness sectors across these regions.Europe continued to be affected by the Russia-Ukraine war,which not only disrupted flight paths and tourism flows(and hence,the wellness tourism,spa,and thermal/mineral springs sectors)but also investments and trade in food,energy,and many goods and services.The war has also contributed to inflation and higher energy prices.Elsewhere,the Israeli-Gaza conflict,which began in late 2023,is threatening a wider regional war,and its full impact on the region,on the global economy,and on the wellness economy will become evident when we aggregate the wellness economy data for 2024.In 2022 and 2023,a cautious economic outlook reflecting an environment of rising interest rates,persistent inflation,and fear of recession has served to rein in consumer spending,including on wellness.After a-4.6%drop in 2020,global consumer spending increased by 13.1%in 2021,but then grew by only 4.5%in 2022 and 5.4%in 2023(according to Euromonitor data).China,the worlds second largest economy(and second largest wellness economy),finally opened up in 2023 after three years of stringent pandemic restrictions.After a 19.5%increase in 2021,Chinas GDP growth plummeted to 0.5%in 2022 and then fell by-1.0%in 2023,when measured in U.S.dollars.(Note that these growth rates are affected by currency fluctuations against the U.S.dollar;when measured in local currency,Chinas GDP growth was 11.7%in 2021,and then 5.0%in 2022 and 4.0%in 2023).Consumer sentiment in China has been weakened,and the general economic outlook remains sluggish in an environment of slower investment and export growth,a real estate market crash,and rising youth unemployment.In the pre-pandemic era,Chinese outbound tourists were a global tourism force,with outbound trips(many of which were made in Asia)reaching 155 million in 2019(according to UNWTO data).Outbound trips from China plunged to 20 million in 2020,with further declines in 2021 and 2022.This made a huge impact on the global wellness tourism industry,with the impact especially felt in the Asian markets.While Chinese tourists began traveling again in 2023,outbound Chinese travel has been slow to recover,as consumer behavior,flight availability,and global conditions have changed considerably,and many Chinese are now favoring domestic travel.Across the world,the Asia-Pacific region has been the slowest to recover from the pandemic,especially in the tourism sector.As of 2023,inbound tourism trips to the Asia-Pacific region were at only 71%of their pre-pandemic/2019 levels,while domestic trips were at 86%(based on Euromonitor data).The lagging tourism recovery has continued to affect regional and global wellness tourism,as well as adjacent sectors such as spas and thermal/mineral springs.Inflation rates around the world have moderated somewhat,at 6.8%in 2023 as compared to 8.7%in 2022(IMF data),but they are still significantly higher than in the pre-pandemic period.The Middle East and Central Asia,Sub-Saharan Africa,and Latin America-Caribbean regions continued to experience persistently high inflation rates,in the range of 14.4%-16.7%in 2023.Higher inflation rates have boosted the wellness economy figures in many markets across the world,which means that consumers may just be spending more money on their wellness-related purchases because prices are higher,rather than buying more wellness products and services.We should note that since the global wellness economy is measured in U.S.dollars,its size and growth rates are affected by currency fluctuations against the U.S.dollar across many countries.For example,the Euro rose by 2.6%against the U.S.dollar in 2023,effectively giving 14|Global Wellness Institutethe growth rate of the wellness industry in those nations a 2.6%boost.In contrast,the Chinese Yuan depreciated by 5.1%in 2023,correspondingly reducing the size of the Chinese wellness economy and its growth rate.The Japanese Yen depreciated by 19.8%in 2022 and then by 6.8%in 2023;that depreciation has continued to distort the size and the growth of Japans wellness sectors,when measured in U.S.dollars.For example,Japans wellness economy grew by 10.2%in 2022-2023 when measured in Yen,but it grew by only 3.2%in U.S.dollars.In Japan,a large number of wellness sectors have not yet recovered to their pre-pandemic sizes when measured in U.S.dollars,even though they have fully recovered in Yen(e.g.,physical activity,workplace wellness,wellness tourism,spas,thermal/mineral springs,healthy eating).Since Japan is such a large share of Asias wellness market,this has a dampening effect on the overall growth rates for the region(as noted on Page 5).Many countries and regions across the world are already experiencing the enormous human and economic costs of climate-related events,such as extreme heat,hurricanes,wildfires,floods,and droughts.Recent research indicates that our changing climate will shrink the global economy and reduce human well-being.5 Climate change has already affected the prices of wellness-related goods and services(from food to hotel rooms),as well as consumer behaviors(such as where,when,and how people exercise,eat,travel,socialize,work,and live).Increasingly,the changing climate will create new winners and losers in the wellness economy,both across wellness sectors and subsectors,and across different countries and regions.5Kotz,M.,Levermann,A.&Wenz,L.(2024).The economic commitment of climate change.Nature,628,551-557.https:/doi.org/10.1038/s41586-024-07219-0.Global Wellness Economy Monitor 2024|15What is the future of the wellness economy?As noted above,wellness has become a dominant consumer value worldwide.Now that most of the wellness sectors have exceeded their pre-pandemic levels and reached new heights,what is the outlook going forward?Projected Average Annual Growth Rate by Sector2023-2028Source:Global Wellness Institute and IMFWellness Real EstateWellness TourismThermal/Mineral SpringsMental WellnessSpasTraditional&Complementary MedicineHealthy Eating,Nutrition&Weight LossPhysical ActivityPersonal Care&BeautyWorkplace WellnessPublic Health,Prevention&Personalized Medicine6.1%5.8%5.4%4.8%3.1.8.2.2%9.2%6.4%Wellness Economy 7.3%Global GDP4.8%0 2%4%6%8%6.1|Global Wellness InstituteGWI predicts that the wellness economy will continue its robust growth and expand its share of consumer spending and the global economy over the next several years.The underlying forces that propel the growth of wellness remain as compelling as ever,including:population aging,the rise of chronic disease,the unsustainable costs of the sick-care model,widespread mental unwellness,and expanding awareness of healthy lifestyles and wellness modalities.There is no question that consumer interest in all things related to wellness has been rising rapidly and has accelerated during the pandemic to become a permanent shift.There is also a growing awareness of the environmental determinants of health,whether we are at home,at work,in our community,or traveling.Wellness has expanded to encompass many stakeholder groups beyond hospitality,leisure,and personal care;it is being embraced by more businesses and brands(e.g.,sports and entertainment,finance,technology,big foods,fashion,automobiles),employers,nonprofits,public health,urban planning,and more and these stakeholders will increasingly take wellness to more consumers and to the masses.For the next five years,we project that the global wellness economy will grow at a robust rate of 7.3%annually,a growth rate substantially higher than the projected global GDP growth(4.8cording to current IMF forecasts).As all of the eleven sectors recover from the pandemic,the wellness economy is expected to reach nearly$6.8 trillion in 2024,and march toward nearly$9.0 trillion in 2028.Most of the individual wellness sectors are projected to exceed global GDP growth in the next five years(with the exception of workplace wellness and personal care&beauty).Some of the sectors with the highest growth projections(e.g.,wellness tourism,thermal/mineral springs)are those that took the greatest hit in 2020.The growth rates for these sectors may seem abnormally high because they reflect a continued period of recovery through 2024,and they are then expected to taper off a bit.Both the thermal/mineral springs and workplace wellness sectors are projected to fully recover and exceed their pre-pandemic levels in 2024.Other sectors that maintained positive growth throughout the pandemic,including wellness real estate and mental wellness,are projected to continue their very strong growth trends in the coming years.In our forecasts,five wellness sectors personal care&beauty;healthy eating,nutrition,&weight loss;physical activity;wellness tourism;and public health,prevention,&personalized medicine will exceed$1 trillion in market size by 2028.We currently project that personal care&beauty will remain the largest segment in the wellness economy through 2028.With its ongoing strong growth rate,wellness real estate will enter the top six sectors in by 2026.By 2028,we project that the global wellness economy will represent 6.8%of global GDP,as compared to 6.0%in 2023.Global Wellness Economy Monitor 2024|17Wellness Economy Growth Projections 2023-2028Market Size (US$billions)Projected Market Size (US$billions)Projected Average Annual Growth Rate20192023202420252026202720282023-2028Personal Care&Beauty$1,071.9$1,212.7$1,268.3$1,328.0$1,392.7$1,463.3$1,535.24.8%Healthy Eating,Nutrition,&Weight Loss$912.4$1,095.7$1,160.7$1,238.7$1,319.9$1,403.8$1,492.56.4%Physical Activity$903.9$1,059.7$1,125.4$1,194.9$1,261.4$1,333.4$1,407.75.8%Wellness Tourism$696.6$830.2$944.0$1,049.2$1,150.0$1,249.8$1,351.010.2%Public Health,Prevention,&Personalized Medicine$443.9$781.0$827.5$877.9$931.4$988.0$1,047.66.1%Wellness Real Estate$225.2$438.2$512.7$608.3$705.6$807.2$912.615.8%Traditional&Complementary Medicine$483.0$553.0$577.3$611.7$646.2$681.5$718.45.4%Mental Wellness$150.0$232.6$256.6$286.3$321.2$364.9$414.012.2%Spas$116.3$136.8$148.1$158.0$167.1$175.8$184.36.1%Thermal/Mineral Springs$65.8$62.7$69.6$75.8$83.1$90.3$97.69.2%Workplace Wellness$51.8$51.8$52.7$54.0$56.0$58.2$60.33.1%Wellness Economy$5,030.0$6,321.2$6,797.3$7,321.9$7,854.9$8,411.6$8,989.47.3%Note:Figures do not sum to total due to overlap in segments.Source:Global Wellness Institute estimates,based upon economic and industry sector projections from the IMF,ILO,Euromonitor,and GWIs data and projection model.18|Global Wellness InstituteWhy is it important to measure the wellness economy?As wellness becomes increasingly ubiquitous and embedded in our everyday lives,it is easy to forget that just a decade ago,there was no broadly agreed definition of what“wellness”is,let alone an industry called“wellness.”Like many important industries that have emerged in the last 50 years such as the IT industry,and the sustainability or“green”industry the wellness industry is not measured in any standard industry datasets compiled by governments and multinational organizations.The Global Wellness Institute(GWI)began measuring the size of the global wellness economy in 2014,when we published the first Global Spa&Wellness Economy Monitor.6 The definition and quantification of wellness as a major global industry has had many important impacts:The wellness economy figures are an important resource for investors and businesses within the wellness industry and in adjacent spaces,in order to understand the size,future trajectory,and opportunities within this incredibly diverse sector that intersects with many other industries.By defining wellness and the industry sectors that are part of the wellness economy,we help businesses and entrepreneurs recognize wellness as a cohesive industry,understand how different pieces are connected,and identify opportunities for collaboration and integration.Definitions are critical for the wellness economy and all its sectors,requiring discipline and a thorough understanding of wellness both as a concept and as an economic activity.If the definition is too narrow,it would limit imagination and innovation.If it is too broad,then everything could be considered“wellness,”rendering the measurement meaningless.If the definition is too vague or opaque,then the user would not know what the data are measuring.Our definitions require us to delineate a boundary around specific activities,services,and products in each wellness sector,in order to measure its market size.By articulating“new”wellness sectors that were not well understood before(e.g.,wellness tourism,wellness real estate,mental wellness),we bring attention to these emerging sectors and help them to attract investors and partners,and eventually take off.Measuring the wellness economy helps to raise the industrys profile among consumers,entrepreneurs,investors,governments,and the research community.Having global data on the size and growth of the industry creates greater awareness of the consumer demand in the wellness space,stimulates new business ideas,and invites innovation.It also attracts more scientific and clinical research on ancient and emerging wellness modalities.The wellness economy as we define it encompasses a diverse set of eleven industry sectors.We acknowledge that other researchers,economists,and industry analysts may have differing opinions on what constitutes the global wellness industry.The data presented in this report are based on the GWI research teams sixteen years of work in this space,as well as our collaborations with industry stakeholders worldwide,to understand the history and concept of wellness,how it is translated into economic activities,and how these activities can be defined and quantified.Business and investors can benefit from many sources of data and measurements,and we welcome other industry and research organizations to join the effort.However wellness may be defined or measured,it is critical that any measurements of the global wellness industry are based on concise definitions;promote transparency on what is being measured and the methodologies employed;and adopt uniform estimation methodologies in each wellness sector and across different countries and regions.6Yeung,O.,and Johnston,K.(2014).Global Spa&Wellness Economy Monitor 2014.Miami,FL.:Global Wellness Institute.https:/globalwellnessinstitute.org/industry-research/global-spa-wellness-economy-monitor-2014/.Global Wellness Economy Monitor 2024|19How to interpret the wellness economy numbers.We measure the wellness economy in nominal figures i.e.,the figures are not adjusted for inflation or purchasing power.While inflation rates around the world have moderated a bit to 6.8%in 2023,inflation is still significantly higher than it was in the pre-pandemic period.At the same time,some major currencies have depreciated against the U.S.dollar in 2023(such as the Chinese Yuan and Japanese Yen),while others have risen in value(such as the Euro).These factors have both upward and downward effects on the wellness economy figures across various countries,and the combination of impacts is different in every market.Therefore,depending on the inflation rate and the currency rates,a higher number in 2023 may not mean that more services and goods are being consumed,and could simply reflect that people have to pay more money for the same items,or that those goods and services have become more expensive in U.S.dollars.What we measure as the wellness economy only includes the goods and services that are being marketed and sold as“wellness”in the consumer marketplace.We are not measuring the wellness activities of the population in each country,and we are not measuring peoples health or well-being.By including particular sectors,services,or products in our wellness economy data,we are not endorsing these things as being essential to wellness,and we are not implying that they are beneficial,or scientifically proven to improve health and well-being.Our measurement methodology does not apply a value judgement on what should or should not be considered“wellness.”Rather,we objectively include products and services that are proactively labeled and positioned by businesses as“wellness”and are most closely identified by consumers as such.The growth of the wellness economy indicates rising overall spending on wellness activities,products,and solutions,but not necessarily better accessibility to more people.As the wealth/income gap widens across the world,there is a growing trend of wellness offerings becoming ever more luxurious,exclusive,personalized,and expensive.This premiumization can be observed in many wellness sectors,such as high-end wellness tourism,luxury wellness real estate,boutique fitness,premium personal care and beauty products,and high-tech longevity medicine.Therefore,it is possible that the growth in certain wellness sectors is being driven by small segments of consumers making more expensive purchases,and not by an expanding pool of wellness consumers.The rise of some wellness services and products can marginalize important populations.For example,the ever-growing adoption of health and wellness technologies often works under the assumption that apps and digital solutions will automatically improve the experiences and health outcomes for everyone.This may not be the case for people who have limited digital access or low tech-readiness(i.e.,limited ability to use technology and access platforms).These populations may include seniors,people who live in rural areas,poor people in wealthy countries,and the wide swath of the population in the developing world who can hardly afford their mobile phones.A study led by the Alliance for Affordable Internet found that 2.5 billion people pay more than 30%of their monthly incomes to purchase the cheapest smartphone available in their markets.7 Given this disparity,the increasing reliance on and investments in such tech-based health and wellness services may be marginalizing the populations who have the greatest needs.7Alliance for Affordable Internet(2022,Aug.31).The cost of smartphones falls,but they remain unaffordable for billions around the world.A4AI News.https:/a4ai.org/news/the-cost-of-smartphones-falls-but-they-remain-unaffordable-for-billions-around-the-world/.20|Global Wellness Institute The wellness economy does not capture the many important wellness-enhancing activities and behaviors that cannot be monetized.It is important for people to know that wellness does not require spending extra money,such as:the enjoyment of nature;a diet of local,fresh,whole foods;friendship and community;altruism;religion and spirituality;movement embedded in daily activities(e.g.,working outdoors,gardening,or cycling/walking to work or school);and much more.In the places where wellness is already embedded in the culture,the natural/built environment,or by deliberate policy,the wellness economy is likely to be smaller.Greater public investment in wellness infrastructure that is accessible to everyone(e.g.,walkable cities,cycling/walking trails,outdoor gyms,fresh produce markets,public squares and gardens)may reduce the need for consumer spending on services and products in the marketplace.The practice of holistic wellness is blurring boundaries and accelerating the convergence of many sectors within the wellness economy.In particular,the wellness real estate,workplace wellness,and wellness tourism sectors encompassing the environments where we live,work,and play increasingly incorporate elements from many other wellness domains,such as physical activity,healthy eating,mental wellness,and public health.Now,fitness businesses are moving into hospitality,spa,weight loss,healthy eating,mental wellness,and traditional&complementary medicine.They are offering to help people who take GLP-1 drugs to prevent muscle loss,and they are marketing$40,000-a-year memberships for concierge,personalized,prevention,and wellness programs(e.g.,Equinox).Even global tech and entertainment giants are entering the wellness arena(e.g.,Apple Fitness,YouTube exercise programming,Metas VR Fitness).As much as we try to segment the wellness economy into eleven discrete sectors,the growing convergence is making this effort increasingly challenging.The wellness economy is dynamic and rapidly evolving.New practices,modalities,and discoveries are constantly emerging to meet the peoples changing needs.In recent years,many new possible wellness sectors and categories have been coined by journalists,analysts,and entrepreneurs for example,sexual wellness,hormonal wellness,childrens wellness,financial wellness,end-of-life wellness,etc.The absence of a specific designation for these categories in our wellness economy construct does not mean that they are not important or significant.Many of these“new”activities and services are already captured in existing wellness sectors,such as public health,prevention,&personalized medicine;traditional&complementary medicine;healthy eating;mental wellness;and others.Some of the fast-growing opportunities are occurring in the medical and pharmaceutical arenas(e.g.,psychedelics,or the newly exploding market for weight loss drugs),and,therefore,they are not considered part of the wellness economy in our definition.Other innovations and popular new modalities are embedded across multiple wellness sectors(e.g.,leveraging nature,pro-social approaches,AI,VR,touchless technology,biofeedback),making them difficult to define and measure in meaningful ways.In 2020,we added mental wellness as the eleventh sector in the wellness economy,in response to the massive growth and expansion of the consumer market in this space.In the future,the GWI research team will continue to monitor and evaluate developments in the wellness economy,and we will align our definitions and measurements with emerging needs and developing business segments.*The following chapters of this report present detailed data and analysis for each of the eleven wellness economy sectors.Global Wellness Economy Monitor 2024|21CHAPTER 2 Wellness Real EstateSector DefinitionExpenditures on the construction of residential and commercial/institutional properties(including office,hospitality,mixed-use/multi-family,medical,and leisure)that incorporate intentional wellness elements in their design,materials,and building,as well as their amenities,services,and/or programming.HistoricalProjectionCAGR=Compound Annual Growth RateSource:Global Wellness Institute20172018201920202021202220232024202520262027$1,000$900$800$700$600$500$400$300$200$1000US$billions$148.5$225.2$342.0$912.62028$386.6Projected15.8GR$274.0$438.2Global Market Size and Growth Projections18.1GR2019-2023$438.2bGlobal Market In 202322|Global Wellness InstituteWellness Real EstateMarket size and growthWellness real estate has long been the fastest-growing sector in the wellness economy.The COVID-19 pandemic has only accelerated a growing understanding among consumers and the building industry about the critical role that external environments play in our physical and mental health and well-being.During the pandemic year(2019-2020),wellness real estate was one of the few wellness sectors that continued to grow rapidly(21.6%growth),even as overall construction output and global GDP shrank(-0.8%and-2.6%,respectively8).From 2019-2023,the wellness real estate sector has maintained a robust average annual growth rate of 18.1%,as compared to 5.1%average annual growth for overall construction.GWI estimates that the wellness real estate market rose to$438.2 billion in 2023,representing about 2.9%of global annual construction output.We project 15.8%annual growth over the next five years,with the market increasing to a projected$912.6 billion by 2028.Wellness Real Estate Market by Region 2019-2023Wellness Real Estate Market Average Annual Growth Rate(US$billions)Per Capita 20232022-20232019-2023201920202021*2022*2023North America$100.19$118.82$146.89$175.99$193.98$518.2910.2.0%Asia-Pacific$77.51$97.70$119.36$127.33$145.33$33.9814.1.0%Europe$46.03$55.84$73.68$80.72$95.91$104.0918.8 .1%Middle East-North Africa$0.71$0.78$0.96$1.21$1.41$2.6015.7.7%Latin America-Caribbean$0.55$0.61$0.80$0.95$1.21$1.8226.7.0%Sub-Saharan Africa$0.24$0.25$0.30$0.34$0.39$0.3113.2.1%WORLD$225.23$273.99$342.00$386.56$438.22$54.6213.4.1%*2021 and 2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions and updates made by key underlying data sources such as the United Nations.Note:Figures may not sum to total due to rounding.Source:Global Wellness Institute,based on construction output data from the United Nations.8Global construction figures estimated by GWI,based on data from:United Nations Statistics Division,National Accounts Official Country Data Database,https:/unstats.un.org/unsd/nationalaccount/default.asp,accessed 26 March 2024.Global GDP data from:IMF,World Economic Outlook Database,April 2024 Edition,https:/www.imf.org/en/Publications/WEO/weo-database/2024/April.Global Wellness Economy Monitor 2024|2330% %5%0Wellness Real Estate Versus Construction Output,Regional Compound Annual Growth Rate,2019-2023North AmericaMiddle East-North AfricaLatin America-CaribbeanEuropeAsia-PacificSub-Saharan Africa22.0%6.9 .1.7.0%6.3%1.9%6.2.0%4.3.1%3.3 19-2023 Wellness Real Estate CAGR2019-2023 Total Construction Output CAGRCAGR=Compound Annual Growth RateSource:Global Wellness Institute,based on construction output data from the United Nations30% %5%0-5%Wellness Real Estate Versus Construction Output,Global Annual Growth Rate,2019-20232019-20202020-20212022-20232021-202221.6%-0.8$.8.7.0%3.4.4%1.9%Wellness Real Estate Annual Growth RateTotal Construction Output Annual Growth RateSource:Global Wellness Institute,based on construction output data from the United Nations24|Global Wellness InstituteThe wellness real estate market is heavily concentrated in North America,Asia-Pacific,and Europe;these regions together account for 99%of the global market.North America remains the largest regional market in 2023,accounting for 44%of the global total.Because the COVID-19 pandemic was such a massive economic shock around the world,the current analysis of industry growth tends to focus on pre-and post-pandemic shifts,or a 2020 dip and post-2020 recovery.Wellness real estate is a unique case since this sector maintained a strong growth rate throughout the pandemic,we can focus on the longer-term,uninterrupted growth trend.Over the last couple of years,global construction growth has slowed considerably,from 16.7%growth in 2020-2021 to only 1.9%growth in 2022-2023.This shift has been driven by an overall slowdown in economic growth,a major real estate crisis in China(which is the worlds largest construction market),and a negative construction market growth rate across several regions in 2022-2023,including Asia-Pacific(-1.3%),Middle East-North Africa(-2.2%),and Sub-Saharan Africa(-7.6%).While the growth rate for wellness real estate has remained well above that for overall construction,the sectors annual growth rate has also tapered off a bit in the last few years,from a 24.8%increase in 2020-2021 to 13.4%growth in 2022-2023.At the regional level,wellness real estate growth has outpaced overall construction growth across every single region from 2019-2023,by a factor of 3-4 times or more.Latin America-Caribbean and Europe have been the fastest-growing regional markets for wellness real estate over the 2019-2023 time period,mirroring their relatively high growth rates for overall construction.North America has maintained a very strong growth for wellness real estate ever since GWI started measuring this sector in 2017,but the regional growth rate has tapered off in 2022-2023 alongside a slowdown in overall construction.Interestingly,Middle East-North Africa has remained one of the fastest-growing regional markets for wellness real estate investment over the last four years,even alongside relatively slower construction growth(and including a significant construction downturn in 2022-2023).Asia-Pacific is home to a number of very large and fast-growing countries for wellness real estate(e.g.,Australia,Japan,China,India),but the overall regional growth trend in the last several years has been dampened by economic volatility and a construction market downturn across a number of countries in 2022 and 2023(including China,Japan,and South Korea).Global Wellness Economy Monitor 2024|25The top twenty largest country markets for wellness real estate have remained the same since 2019,with very little movement up or down within these rankings.The list of the largest markets further illustrates how heavily concentrated the wellness real estate sector is in just a few major countries.The United States accounted for 41%of the global market in 2023.The United States and Canada,plus a few key countries in Asia(China,Australia,Japan)and Europe(United Kingdom,France,Germany),accounted for 85%of the global market.Average annual growth rates for 2019-2023 remained quite high across all of the largest country markets,and many of the countries on this list have been growing faster than the global sector average(18.1%)during this time period.Wellness Real Estate:Top Twenty Markets in 2023Wellness Real Estate Market Average Annual Growth Rate(US$billions)Rank in 20232022-20232019-2023201920202021*2022*2023United States$94.32$110.99$136.85$164.22$180.65110.0.6%China$36.96$50.90$62.13$63.37$72.74214.8.4%United Kingdom$10.77$14.76$21.40$23.37$28.89323.6(.0%Australia$15.58$16.54$21.12$22.52$25.65413.9.3%France$9.55$11.24$15.47$16.91$20.70522.4!.3%Japan$7.60$11.47$13.21$14.99$17.05613.8.4%Germany$8.67$9.71$11.10$12.16$13.69712.6.1nada$5.87$7.83$10.04$11.77$13.33813.3.7%South Korea$5.67$6.17$7.16$8.37$9.50913.4.8%India$5.01$5.25$7.00$8.12$9.081011.8.0%Netherlands$2.88$4.00$5.50$6.29$7.511119.5.1%Switzerland$2.27$2.51$2.88$3.08$3.561215.4.9%Norway$2.04$2.30$2.80$3.22$3.35134.0.1%Sweden$1.63$1.80$2.71$2.84$3.201412.5.3%Italy$1.29$1.46$2.07$2.17$2.581519.0.0%Austria$1.50$1.73$2.06$2.22$2.43169.4.9%New Zealand$1.47$1.55$1.91$2.06$2.291711.0.8%Singapore$1.14$1.25$1.71$2.07$2.291810.2.9nmark$1.32$1.52$1.81$1.95$2.181912.0.4%Finland$1.02$1.19$1.40$1.55$1.742012.3.3%*2021 and 2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions and updates made by key underlying data sources such as the United Nations.Source:Global Wellness Institute,based on construction output data from the United Nations.26|Global Wellness InstituteOne good way to understand the rapid growth trajectory of wellness real estate is to look at the number of projects earning wellness building certifications in recent years.The WELL Building Standard(WELL)and Fitwel are the two major third-party rating systems that focus specifically on health and wellness of building occupants and that operate in multiple countries.WELL awarded its first certifications in 2014,while Fitwel certified its first projects in 2016.As illustrated below,interest in wellness certifications has risen rapidly since that time,with the total number of wellness-certified building projects increasing by more than forty-fold from 2017 to 2023.At the end 2023,there were over 3,300 WELL and Fitwel certified projects around the world.Over 55%of these certifications are located in the United States.The majority of the certifications are for office/commercial,hospitality,and retail properties,with about 19%in residential projects.As of March 2024,an additional 1,800 projects were in progress for certification(Fitwel)or pre-certified(WELL),with the majority of these located in the United States,China,and Canada.It is important to keep in mind that WELL and Fitwel certifications represent only a small fraction of the wellness real estate market as defined by GWI.The impact of these rating systems extends far beyond the simple number of certifications awarded.For example,large,multi-location companies are increasingly consulting with these rating systems to enhance healthy features across their entire portfolio of buildings,even though they may only officially certify their headquarters.Although WELL and Fitwel are the most well-known and most global programs,a wide range of other wellness-related certifications and toolkits are available in the market,many of which focus more broadly on sustainability or regenerative living rather than just wellness(e.g.,Living Building 4,0003,5003,0002,5002,0001,5001,000500019811947001,5082016201720182019202020212022Cumulative#of WELL/Fitwel Certified ProjectsWELL and Fitwel CertificationsCumulative,2016-2023These figures measure fully certified projects,and they are cumulative(showing the increase in the total number of certified projects over time).Data compiled by GWI using publicly-available online project databases from WELL and Fitwel.Note that the data have been revised slightly since the previous version of the Wellness Economy Monitor,due to changes in these underlying project databases.Source:Global Wellness InstituteTop 10 in 2023United States(1,870)China(411)Canada(298)United Kingdom(134)France(84)Spain(77)Australia(68)India(63)Netherlands(49)Japan(45)2,60720234303,375Global Wellness Economy Monitor 2024|27Challenge,One Planet Living).9 In recent years,well-established green building certifications like LEED and BREEAM have been shifting toward a more holistic emphasis on human health and have added criteria related to indoor environments and occupant health and well-being.10 In Japan,the government has worked with the Institute for Building Environment and Energy Conservation(IBEC)to develop a health and wellness certification for offices as part of the countrys CASBEE certification system.The first project evaluations took place in 2019,and 153 properties have been certified as of April 2024.11 9 For a more comprehensive list of wellness-related certifications,toolkits,and design principles,see:GWI(2018),Build Well to Live Well,https:/globalwellnessinstitute.org/industry-research/wellness-real-estate-communities-research/.10For more information,see:https:/ and https:/www.usgbc.org/articles/human-health-and-wellbeing-through-leed.11See:1)Japan readies certification for healthier office buildings.Nikkei Asian Review.16 Aug.2017.https:/ Wellness Office Evaluation Certification.IBEC.http:/www.ibec.or.jp/CASBEE/certification/WO_certification.html.28|Global Wellness InstituteWellness Real EstateDefinitions:What we measure and what we do notWe define wellness real estate as buildings,neighborhoods,and communities that are proactively designed and built to support the holistic health of their residents,occupants,and visitors.12 Following this definition,we measure the wellness real estate market by estimating expenditures on the construction of residential and commercial/institutional properties(including office,hospitality,mixed-use/multi-family,medical,and leisure)that incorporate intentional wellness elements in their design,materials,and building,as well as their amenities,services,and/or programming.Certifications and rating systems,such as the ones noted above,are becoming increasingly popular as developers are looking for templates and guidance for incorporating wellness design into their projects.Certifications are also a useful signal to tenants about what wellness features a building offers.Beyond these certifications,there is a vast and ever-growing array of wellness-focused buildings and real estate projects around the world,in both new developments and the redesign of existing properties.The diversity of the market is especially apparent in the residential space,where for over two decades,developers and builders have been experimenting with different ways to protect and enhance residents health and well-being through the built environment.Many different types of wellness living concepts are being developed across all types of residential projects,including master-planned communities;multifamily projects(apartments and condominiums);urban districts and mixed-use projects;resort/spa/hospitality-based wellness real estate;affordable/subsidized housing;and other wellness concepts based on eco-communities,co-living,senior living,and more.Our measurement of the wellness real estate market tries to capture these developments,and it is important to note that wellness real estate is not limited to those developments that have obtained certifications.Wellness real estate is extremely diverse,and it is not possible to create a checklist of what we do and do not count as“wellness real estate”when we estimate the size of this market.Wellness real estate concepts can encompass many different elements that address different aspects of our health and well-being,including some or all of the following:Physical wellness:Both passive and active design features enhance occupants physical health and encourage physical activity.Materials,fixtures,and furnishings are non-toxic and health-enhancing,ensure clean air and water,and support good sleep.Design,amenities,and services encourage exercise,active recreation,active transportation(walking,cycling,etc.)and other healthy behaviors.Residents have easy access to healthy foods as well as preventive health/wellness services.Examples:fitness/wellness facilities;walking trails;parks and playgrounds;car share;bike racks;circadian lighting;thermal comfort;air circulation;etc.12 GWI defined and measured wellness real estate for the first time in the 2018 research report,Build Well to Live Well.In that report,we focused more narrowly on“wellness lifestyle real estate”or the residential portion of the market.In this report,we use a broader definition to measure the sector,encompassing both residential and commercial/institutional properties.See:Global Wellness Institute(2018).Build Well to Live Well:Wellness Lifestyle Real Estate and Communities.https:/globalwellnessinstitute.org/industry-research/wellness-real-estate-communities-research/.Global Wellness Economy Monitor 2024|29 Social wellness:Social connections are facilitated through the design of living spaces,public/common spaces,and amenities/services/programming.Residents are encouraged to get to know their neighbors.Location,transportation,and convenience features in the project design may provide residents with more time to spend on social activities.Examples:layout and circulation of floor plans;multigenerational units;common/public spaces;community events/programs;etc.Mental/emotional/spiritual wellness:Project,design,amenities,and services facilitate residents mental,emotional,and spiritual wellness by encouraging connection with nature and animals(biophilia),connection to culture and traditions,connection to beauty,and connection to a greater purpose.The design may provide space and support for contemplation,rest,and solace;encourage residents to pursue personal hobbies,interests,and spiritual practices;and support residents in managing technology and work/life balance.An emerging understanding of how our minds respond to multiple senses(sight,sound,scent,and feel)will increasingly inform mental wellness design in the future.Examples:natural,biophilic,or aesthetic design and materials;green space and water features;public art;meditation spaces;etc.Environmental wellness:Materials,design,and construction are non-toxic,renewable,waste-reducing,energy efficient,natural/organic,and/or locally sourced.The design encourages residents to adopt a lifestyle that is sustainable and regenerative,supporting behaviors such as use of public and alternative transit(less driving),reduce/reuse/recycle,community gardening and local food production,conservation of natural resources,and preservation of green space and animal habitats.With the rise of extreme weather,climate-adaptive features that enhance resilience will emerge in future wellness real estate design.Examples:preserved open space/wetlands;clean/green energy and energy-independent communities;green roofs and heat-reflecting materials;recycling and composting programs;native or edible landscaping;community garden or community supported agriculture(CSA);etc.Community wellness:By design,the project or community supports and embraces diversity(e.g.,mixed-use,mixed incomes,mixed ages,and diverse races and cultures).Residents are encouraged to engage with and care about the wider community and people outside their immediate social spheres.Design of living spaces,public/common spaces,and amenities/services facilitates strong social capital,trust,and civic engagement.Examples:scale and situation of homes relative to others;connectivity and flow of streets;diverse housing types/prices;public plaza/parks;community center;community events and programs;etc.Economic/financial wellness:The community enables residents to conduct their daily activities,such as work,school,shopping,recreation,etc.within a short distance and with different transportation options.Housing in the community is affordable at a variety of income levels,and residents have an opportunity for upward mobility over time.Examples:mixed-use planning/zoning;walkable“town center”and schools;live-work units;co-working facilities;affordable housing policy;public transit planning;etc.30|Global Wellness InstituteIt is important to recognize that healthy communities and health/wellness in the built environment do not always require purpose-built wellness real estate.While we do not specifically measure these as part of our wellness real estate data,“wellness communities”can and do exist independently from wellness real estate in many places around the world.For example,the“Blue Zones”are communities identified around the world that exemplify the critical habits,values,and lifestyles leading to a long,healthy,and happy life.13 In Japan,dozens of cities participate in a Smart Wellness City initiative,where local governments support healthy aging in the community by improving parks,sidewalks,and city aesthetics;developing community fitness programs;making more digital health tools available;and investing in public transit and walkability to promote active transportation and socialization.14 The Wellness Valley in Romagna,Italy,is a self-branded wellness district that links thousands of local businesses,organizations,and individuals together to provide services,programming,and events that encourage exercise,sports,mind-body health,slow food,and connections to nature and culture.15 All these communities provide a collective culture and lifestyle of wellness for their residents,bringing many similar benefits to wellness real estate,without having to invest in intentional,purpose-built developments.When governments invest more in health-enhancing and environment-protecting infrastructure at the neighborhood,community,city,and regional levels,purpose built/privately developed wellness real estate may become less necessary.These kinds of public investments can include active design,public transit,public parks,trails,sports and recreation facilities,community centers,community events,and much more.However,until populations around the world have direct access to these kinds of healthy built environments,wellness real estate will continue to see rising demand and adoption in the foreseeable future.13See:Buettner,D.(2016,November 10).Power 9:Reverse Engineering Longevity.https:/ Wellness Economy Monitor 2024|31HistoricalProjectionCAGR=Compound Annual Growth RateSource:Global Wellness Institute20172018201920202021202220232024202520262027$1,600$1,400$1,200$1,000$800$600$400$2000US$billions$1,407.72028$819.8$903.9$975.6$1,009.7$1,059.7Projected5.8GR$859.3$771.7Global Market Size and Growth ProjectionsCHAPTER 3Physical ActivitySector DefinitionConsumer spending associated with intentional physical activities performed during leisure and recreation.$1,059.7bGlobal Market In 20234.1GR2019-202332|Global Wellness InstitutePhysical ActivityMarket size and growthWe estimate the global market for physical activity at$1,059.7 billion in 2023.Among the 11 sectors that we track as part of the wellness economy,physical activity is one of the largest,ranking third in size(after personal care/beauty and healthy eating/nutrition).Physical activity accounted for 16.8%of all wellness economy spending worldwide in 2023.In 2019-2020,physical activity spending declined by 14.6%,due to the pandemic.The sector then rebounded quickly with a 26.4%growth rate in 2021,as businesses and facilities gradually reopened,and people started returning to their regular activities.By 2021,the overall physical activity sector had already recovered and exceeded its pre-pandemic level.Since then,physical activity market growth has continued but leveled off,with a 5.0%growth rate from 2022-2023.We project that the physical activity sector will grow at by 5.8%annually over the next five years,reaching an estimated$1,407.7 billion in 2028.Physical Activity Market by Region 2019-2023Physical Activity Market Average Annual Growth Rate(US$billions)Per Capita 20232022-20232019-20232019*2020*2021*2022*2023North America$319.6$248.5$359.5$385.2$401.3$1,0724.2%5.9%Asia-Pacific$274.9$256.6$297.3$290.8$300.4$703.3%2.2%Europe$232.8$207.2$247.5$249.5$265.4$2886.4%3.3%Latin America-Caribbean$39.3$28.4$35.2$43.3$51.8$7819.5%7.1%Middle East-North Africa$22.6$19.1$23.2$26.7$27.1$501.5%4.6%Sub-Saharan Africa$14.6$11.8$12.9$14.1$13.8$11-2.5%-1.5%WORLD$903.9$771.7$975.6$1,009.7$1,059.7$1325.0%4.1%*2019-2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions and updates made by key underlying data sources such as Euromonitor.Note:Figures may not sum to total due to rounding.Source:Global Wellness Institute.More than 91%of the worlds spending on physical activity takes place in North America,Asia-Pacific,and Europe.In North America,physical activity spending declined severely during the pandemic,but the region quickly bounced back to lead the world as the largest regional market in 2021,2022,and 2023.North America also has by far the highest per capita level of expenditures on physical activity(at$1,072 in 2023).The regional markets in Asia-Pacific and Europe were less negatively impacted by the pandemic in 2020(-6.6%and-11.0%growth rates,respectively),but these two regions have also seen relatively slower growth and recovery in the subsequent years(average annual growth of 2.2%in Asia-Pacific and 3.3%in Europe over 2019-2023).Global Wellness Economy Monitor 2024|33The United States and China are by far the worlds largest markets for physical activity,together accounting for 50%of all spending in this sector.The top twenty markets are primarily concentrated in North America,Asia-Pacific,and Europe,although Mexico,Brazil,and Argentina also rank among the worlds largest markets.As of 2023,most of the top twenty markets have recovered to or exceeded their pre-pandemic(2019)levels of physical activity spending,with the exception of Japan,Brazil,and Russia.These markets have not fully recovered due to currency depreciation against the U.S.dollar;when measured in their local currencies,all three countries now exceed their pre-pandemic levels of spending.Physical Activity:Top Twenty Markets in 2023Physical Activity Market Average Annual Growth Rate(US$billions)Rank in 20232022-20232019-20232019*2020*2021*2022*2023United States$299.2$232.5$339.1$360.7$376.814.5%5.9%China$138.9$134.2$161.9$150.3$155.423.3%2.8%United Kingdom$42.2$35.6$48.5$49.3$52.937.4%5.9%Germany$39.0$36.1$40.0$40.3$41.643.2%1.7%Japan$44.7$40.1$42.5$38.7$37.25-3.8%-4.5%France$26.9$25.5$29.9$28.5$31.6610.7%4.1%South Korea$25.8$24.2$27.5$29.4$26.87-8.7%0.9nada$20.4$16.0$20.5$24.5$24.580.0%4.6%Australia$18.8$18.3$20.2$22.1$24.299.4%6.5%Italy$19.3$16.2$20.9$18.9$19.9105.0%0.7%Spain$16.5$14.4$17.9$18.6$19.1113.0%3.8%Mexico$11.4$8.6$11.4$13.2$17.01228.0.6%India$13.8$10.3$12.6$14.8$16.91314.2%5.2%Brazil$13.4$9.3$9.7$11.6$12.91411.3%-0.9%Russia$13.3$11.6$13.0$13.7$11.915-13.2%-2.7%Switzerland$9.0$8.1$9.0$9.6$10.3167.7%3.5%Netherlands$9.7$8.8$9.3$9.2$10.0178.9%0.6%Argentina$3.4$2.5$3.6$6.6$8.51829.5%.5%Taiwan$6.7$7.0$7.5$7.6$7.9194.3%4.5%Turkey$5.2$4.4$5.0$5.6$7.52033.1%9.3%*2019-2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions and updates made by key underlying data sources such as Euromonitor.Source:Global Wellness Institute.34|Global Wellness InstitutePhysical Activity Market by Subsector 2019-2023Market Size (US$billions)Average Annual Growth Rate2019*2020*2021*2022*20232022-20232019-2023Recreational Physical Activity$425.7$332.0$431.2$467.9$500.06.9%4.1%Sports&Active Recreation$240.9$202.1$257.4$265.8$281.25.8%3.9%Fitness$150.6$99.1$134.4$160.8$173.88.1%3.6%Mindful Movement$34.3$30.8$39.5$41.3$45.09.0%7.1%Enabling Sectors$485.8$450.1$557.0$557.0$578.03.8%4.4%Sports Apparel&Footwear$346.2$301.1$365.4$372.3$395.66.3%3.4%Sports&Fitness Equipment$110.0$112.4$148.6$136.3$128.7-5.5%4.0%Fitness Technology$31.1$39.0$47.1$52.1$57.610.6.6%TOTAL*$903.9$771.7$975.6$1,009.7$1,059.75.0%4.1%*2019-2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions and updates made by key underlying data sources such as Euromonitor.*Figures do not sum to total due to overlap in segments and rounding.Note:See the“Definitions”section for detailed descriptions of the subsectors.Source:Global Wellness Institute.The core of the physical activity market is consumer participation in three types of recreational physical activities:sports and active recreation,fitness,and mindful movement.16 Consumer spending on recreational physical activities generated$500.0 billion in economic activity in 2023,representing 47%of the total physical activity market.Sports and active recreation,which is the largest category of spending,has recovered rapidly from the pandemic.In 2023,this segment reached$281.2 billion,far exceeding its pre-pandemic levels of spending.The pandemic forced people to go outdoors for their exercise and has ignited a renewed interest in nature.Many outdoor sports and recreation activities have gained popularity since the pandemic,including outdoor running,hiking,cycling,skiing,snowshoeing,rock climbing,pickleball,and many others.Note that even though overall spending on sports and active recreation has grown,we estimate that the overall participation rates for these activities remain below their pre-pandemic levels(33.8%participation in 2019,versus 31.9%in 2023).Many types of sports/recreation activities were curtailed during the pandemic stay-at-home orders and facility shutdowns(e.g.,swimming pools,martial arts studios,sports courts,dance classes,youth sports teams),and not everyone has returned to these activities(see further discussion of participation rates below).This means that the average spending per participant has gone up since pre-pandemic,even as participation levels have remained lower.16For a more detailed definition and elaboration of the subsectors that GWI includes in the physical activity market,see:Yeung,O.and Johnston,K.(2019).Move to be Well:The Global Economy of Physical Activity.Miami,FL:Global Wellness Institute.https:/globalwellnessinstitute.org/industry-research/global-economy-physical-activity/.Global Wellness Economy Monitor 2024|35 Fitness was the most negatively impacted segment during the pandemic,due to gym and fitness center closures(both temporary and permanent),with a 34.2cline in spending in 2020.As of 2022,this segment had fully recovered and exceeded its pre-pandemic level,and it continued to grow at a rapid pace of 8.1%in 2022-2023.Note that GWIs measurement of“fitness”is broader than just gyms and fitness studios,and it includes fitness workouts and classes that take place in home-based gyms,community centers,outdoor gyms,schools,hotels,and via online platforms.Even though spending is up,data sources indicate that gym membership and participation rates were not yet back to their pre-pandemic levels in some countries,meaning that people are spending more on their fitness activities.In our data,the fitness participation rate has increased from 5.0%in 2019 to 5.5%in 2023,but this participation measurement encompasses a large and growing number of people doing fitness via streaming services,apps,and at home,in addition to gym memberships.Mindful movement is the smallest segment in terms of spending($45.0 billion in 2023),was the least negatively impacted by the pandemic,and has seen the most growth as compared to its pre-pandemic level(with spending increasing by 7.1%annually from 2019-2023).In particular,yoga has grown rapidly in popularity since the pandemic not only as a good at-home exercise option when gyms were closed,but also as a stress reliever.The rise in free and low-cost digital platforms(including apps,YouTube,etc.)has also allowed a growing number of people to practice yoga and other mindful movement modalities(e.g.,Pilates,tai chi,barre)at home.The physical activity market also includes three supporting segments that enable and facilitate consumer participation in these activities:apparel and footwear,sports and fitness equipment,and fitness technology.Sports apparel and footwear fell by 13.0%in 2020,but has since recovered and exceeded its pre-pandemic level,reaching$395.6 billion in 2023.It is important to keep in mind that activewear/sportswear is increasingly popular worldwide as daily clothing for an aspirational lifestyle(not just for sports/fitness purposes),and this trend has accelerated since the pandemic.Sports and fitness equipment is a broad segment that includes sporting goods,protective gear,and fitness/exercise/training equipment and supplies.This segment has grown to$128.7 billion worldwide in 2023.Some types of sporting goods saw an explosion in demand during the pandemic,especially during the first few months of shutdowns(e.g.,bicycles,kayaks,at-home fitness equipment,connected equipment like Peloton bikes),but the growth has tapered(and even declined)in 2022 and 2023 as people returned to in-person gyms,fitness studios,and sports teams.Fitness technology,which exploded in 2020,has continued its rapid growth 2021-2023.Estimated at$57.6 billion in 2023,the global market for fitness tech includes wearable devices,trackers,and smart/networked equipment,as well as digital platforms(apps and streaming)and software all of which support and encourage peoples participation in fitness and physical activities by making it more convenient,fun,sociable,personalized,trackable,and affordable.We estimate that consumer spending on various types of fitness apps,streaming,and on-demand services(a subsegment within fitness tech)has expanded at a very rapid rate of 23.5%annually from 2019-2023.In comparison,the fitness tech devices/equipment subsegment(e.g.,wearables and smart/networked equipment)has grown by 10.4%annually during this time period.36|Global Wellness InstituteParticipation in Recreational Physical Activity by Subsector 2019-2023Percent of the total population who participate in some type of recreational physical activity on a regular basis(at least monthly)2019*2020*2021*2022*2023By RegionNorth America59.95.56a.68b.61c.50%Europe50.28H.74H.73I.13I.32%Latin America-Caribbean36.713.414.336.025.05%Asia-Pacific33.39).280.571.021.51%Sub-Saharan Africa32.19.74&.14).550.15%Middle East-North Africa25.87#.57$.97%.40%.83%By SectorRecreational Physical Activity36.282.063.454.434.76%Sports&Active Recreation33.80).520.741.691.92%Mindful Movement4.87%5.26%5.38%5.40%5.55%Fitness4.97%3.78%4.85%5.28%5.51%*2019-2022 figures for this sector have been revised since GWI released the previous version of the Wellness Economy Monitor,due to data revisions,updates,and improved data availability across various country sources.Source:Global Wellness Institute,based on a variety of country-level sources and surveys.From a health and wellness perspective,peoples participation in physical activities is far more important than how much money they are spending on these activities.In most(but not all)countries around the world,participation in recreational physical activities declined in 2020,and in most countries,the participation rates have not returned to their pre-pandemic levels.Globally,the percent of the population participating in all types of recreational physical activities has fallen from 36.3%in 2019 to 34.8%in 2023.Looking at the three categories of activities:The participation rate for sports/active recreation in 2023 remains well below its 2019 level.Participation rates for mindful movement increased a lot in 2020-2021 due to the pandemic but growth has leveled off in 2022 and 2023(probably due to some waning interest after the burst during the pandemic,as well as people returning to their pre-pandemic habits and activities).Participation in fitness fell sharply in 2020 and has subsequently grown and now exceeds its pre-pandemic level.The overall increase in the fitness participation rate from 2019-2023 is in part due to rapidly increasing participation in digital/streaming/at-home fitness activities,in addition to people returning to gyms/health clubs/fitness studios in the post-pandemic period.In some countries,gym participation and memberships have not yet fully recovered to their pre-pandemic levels.We estimate that the participation rate for traditional gyms/fitness centers alone has declined slightly from 3.35%in 2019 to 3.32%in 2023.Looking across the worlds regions,North America has been the bright spot,with recreational physical activity participation continuing to rise during and after the pandemic,reaching 63.5%in Global Wellness Economy Monitor 2024|372023.All other regions suffered significant declines in their physical activity participation rates in 2020,and they have not yet returned to their pre-pandemic(2019)levels.Many people around the world conduct their leisure-time physical activity in public places(e.g.,public parks and plazas,community sporting facilities,in the streets),at home,and/or via free digital platforms.This is especially true in lower-income countries,where private fitness and recreational businesses,facilities,and infrastructure are less developed.It is also true in some higher-income markets,where good publicly subsidized recreational infrastructure provides opportunities for greater participation at low out-of-pocket costs.The more people participate in physical activities outdoors,on their own,and using free digital services and the more governments invest in publicly supported physical activity infrastructure the less money people will need to spend out-of-pocket on exercising.Conversely,in some markets we see growing expenditures on physical activities without a commensurate increase in participation rates meaning that the same(or a smaller)share of the population is simply spending more per person on doing these activities.Therefore,there is not a direct line relationship between physical activity spending and physical activity participation.When we measure higher spending in the physical activity market,it does not necessarily mean that people are doing more physical activity,or that more people are doing physical activity.38|Global Wellness InstitutePhysical ActivityDefinitions:What we measure and what we do notThere are two broad types of physical activity:natural movement(movement that is essential to our daily lives,like walking for transportation,jobs that require manual labor,and household chores),and recreational physical activity(movement that we choose in our leisure time,like exercise,playing sports,taking a walk,or playing on a playground).17For the wellness economy data,our definition and measurement of the
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Powered by Branch-CONFIDENTIALHEALTHCARE Mobile Growth PlaybookTable of contentsState of healthcare .
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The Power of Intellectual Property and Innovation in Solving Global Health ChallengesEditors:Mark Schultz,Emily Michiko Morris,Sandra Barbosu and Stephen Ezell Featuring Original Case Studies Authored By:Natalie Khoo Douglas Park Brian Thomson Joshua Villers Kristen ThompsonKrishna Sankya Talluri Mohammed Suleiman Sophia Sterling Tatyana Norman-WeblerThe Power of Intellectual Property and Innovation in Solving Global Health Challenges Many of the worlds biggest challenges are health challenges.The good news is that,more than ever,people are meeting these challenges with innovative solutions.While we still face great difficulties,people all over the world live better than ever before thanks to innovation.New medicines prevent or alleviate disease.New devices diagnose problems,repair bodies,and overcome physical challenges.Still other inventions keep vaccines and medicines fresh and effective or ensure their authenticity.New business models help innovation to happen and ensure that it reaches those who need it.Many of these innovations are secured by intellectual property(IP)rights,which support the ability of innovators to invent and bring solutions to market.Property rights,particularly IP rights,foster the freedom of many hands and minds to work on challenging problems.They put decisions in the hands of those closest to problemsinnovators with knowledge of potential solutions and caregivers and consumers who understand their own needs best.They fund individual careers and industries dedicated to solving health problems,as well as the businesses that get these solutions to individuals.With just a bit of reflection,it becomes clear that innovation and the property rights that secure it are key to meeting global health challenges.Sometimes,however,the blinding light of necessity makes it hard to see this fact.When people are in need,its all too easy to grow impatient with the rights of innovators.When that happens,innovators get treated as an obstacle.We think that better public policy would result from better understanding of how innovation can meet global health challenges.Our organizations,the Information Technology and Innovation Foundation(ITIF),the University of Akron School of Law,and the Geneva Network have teamed up to tell the exciting story of how innovation is making the world healthier.Our Innovate4Health project profiles 26 case studies covering five themes:Removing practical barriers to accessing treatments;Simplifying treatments and diagnostics to make it easier for patients to access and use them;Increasing efficacy and removing the detrimental side effects of existing therapies;Making personalized medicine accessible to more patients;and Reducing the global burden of non-communicable diseases as life expectancy increases.Collectively the case studies describe how entrepreneurs are creating IP-enabled life-sciences innovations that are helping to tackle some of the worlds toughest health challenges.Natalie Khoo Douglas Park ITIF UAIP Innovate4Health 2 Table of Contents The Power of Intellectual Property and Innovation in Solving Global Health Challenges.1 Table of Contents.2 Chapter 1:Introduction/Executive Summary.4 Chapter 2:Challenge:Removing Practical Barriers to Accessing Treatments.9 NIRAMAI Thermalytix:Transforming Early Breast Cancer Detection in India.9 From Plants to Patients:How Intellectual Property Propelled La-Africa Soothers Natural Approach for Pain Relief.12 Herbanext Laboratories Turns Traditional Medicine Into Modern Healthcare.15 Selectivity Life,Harnessing Innovation to Expand Access to Fertility Treatments.17 MScan Uganda is Advancing Maternal Healthcare and Driving Social Impact Through Its Innovative Portable Ultrasound Technology.19 Chapter 3:Challenge:Simplifying Treatments and Diagnostics to Make It Easier for Patients to Access and Use Them.22 Seeing Is Believing:FOODVICAs Innovative Non-Surgical Cataract Treatment.22 Wearable Respiratory Rate Monitoring Glove:A Breakthrough in Childhood Pneumonia Detection in Bangladesh.24 Intellectual Property at Work:How Serenox Africa is Improving Diagnostic Testing in Sub-Saharan Africa.26 Dr.Wedyan Babatain Brings Wearable Medical Tech Closer Than Ever.29 HydroZitLa Uses Native Flora to Help Fight Kidney Stones.32 Chapter 4:Challenge:Increasing Efficacy and Removing the Detrimental Side Effects of Existing Therapies.34 Bio is Tech:Re-Imagine Disease Detection Through Konikus Innovative Odor Surveillance System.34 Calixcoca:A Shot at Sobriety Brazils Innovative Vaccine Aims to Revolutionize Addiction Medicine.37 Innovative Cure For All:How CurASeals Plant-Based Technology Advances Bleeding Control and Wound Healing.40 Andes Biotechnologies Makes Sense of Cancer Treatments with Antisense Technology.42 Pioneering Cell Banking with Paper-Based CryopreservationA New Era in Life Sciences.45 Chapter 5:Challenge:Making Personalized Medicine Accessible to More Patients.47 3 Colombian SmartBone Provides Accessible Custom Craniofacial Implants#Innovate4Health.47 Tinnitus Per Offers Individualized Treatment for Tinnitus Deliverable Remotely.49 Pill.AR:Printing Personalized Medicine with MESO-PP.52 Colombian Knockout Monitor Prevents Anesthesia From Wearing Off During Surgery.54 Chapter 6:Challenge:Reducing the Global Burden of Non-Communicable Diseases as Life Expectancy Increases.57 Trailblazing Colombian Startup Is Changing the Lives of Children Living With Cerebral Palsy.57 NexCAR19:The Future of Lymphoma Treatment in India,and IPs Essential Role.59 Caring Cross and Brazils Fundao Oswaldo Cruz Collaboration Increases Access to Life-Saving CAR-T Cell Therapy in Brazil.62 Itolizumab Provides Relief from Psoriasis,Covid-19,and More.65 Alzheimers Disease Next Game Changer:TauRx Pharmaceuticals Novel Tau Aggregation Inhibitor.67 Asma Saeed Al-Amoodi Innovates Stem Cell Treatments for Leukemia.69 Beyond What Meets the Eye:How SELENA is Revolutionizing the Detection of Eye Diseases.71 Conclusion.74 Endnotes.75 Innovate4Health 4 Chapter 1:Introduction/Executive Summary People face healthcare challenges all around the world,and these challenges can be especially severe in less-wealthy countries.Fortunately,healthcare innovation also happens everywhere,even in areas with limited resources.While theres a global understanding that healthcare innovation is crucial to surmounting these challenges,the remarkable efforts happening on the ground often go unnoticed.Discussions about innovation tend to focus on research in wealthy nations,overlooking the grassroots solutions emerging in less-wealthy regions.This volume aims to highlight the brilliance and dedication of innovators in these areas,showcasing 26 original case studies that demonstrate how local and international actors collaborate to tackle healthcare challenges.By emphasizing innovation in less-wealthy countries,we reveal the powerful grassroots initiatives that occur closer to the point of care.Innovation happens close to home.Our research uncovered a wealth of inspiring stories about entrepreneurs and communities developing solutions tailored to their unique challenges.The findings underscore a vital lesson:those who experience health issues firsthand are often the most adept at identifying and solving them.Their deeply personal understanding leads to inventive approaches that can address even the most-pressing health concerns.These case studies illustrate a hopeful narrative about the power of local innovation to improve health outcomes.Despite limited resources,people have shown remarkable inventiveness and determination.By creating supportive policies and environments,we can augment these efforts,recognizing that those closest to the challenges are often best positioned to craft effective solutions.This collection serves as a tribute to the ingenuity of those working tirelessly to improve health in their communities,offering a fresh perspective on global health challenges and the innovative spirit that drives change in the face of adversity.While these categories represent a broad range of difficulties in the provision of medicine,they nevertheless have one thing in commonthe brilliant minds in the middle of things,working tirelessly to devise solutions that will save their friends,family,and neighbors from suffering.Solutions depend on innovation.Discussions of healthcare policy often revolve around the practical need to contain costs balanced against the need to fund expensive research and development(R&D)to develop innovative new treatments.However,this dichotomy overlooks three realities:First,innovation is often the best way to contain costs.Second,not all innovation is costly.And third,innovation happens everywhere,and effective,lower cost innovation often happens in emerging economies.Economics illustrates just how fundamentally innovation can impact human lives.Innovators produce efficiencies that allow us to overcome scarcity and do more with the resources they have available.Paul 5 Samuelson explained in his introductory economics textbook that“in the world as it is,children learn that both is not an admissible answer to a choice of which one?”Innovation helps defeat the iron law of scarcity.It enables people to do more things with fewer resources,repurpose traditional materials for new uses,and generate entirely new products and industries.In turn,it drives increased output,creates employment opportunities,raises wages,stimulates economic growth,and expands consumer choice.Through innovation,society gains access to previously unimaginable possibilities and capabilities.The role of innovation in driving both economic and social progress is difficult to overstate.The need for innovation also grows ever greater as resources grow scarcer.Medicine must reach people where they are.One of the greatest challenges facing healthcare is simple availability.Over and over,innovators must address the lack of trained professionals,transportation,and other necessary infrastructure.For example,infertility affects approximately 48 million couples and 186 million individuals worldwide,with about 75 percent lacking adequate access to treatment due to financial and infrastructural barriers.1 This is especially true in low-and middle-income countries.Argentinian startup Selectivity Life is addressing this challenge through its patented biomimetic membrane technology for sperm selection,which allows for simplified fertility treatments that can be performed in a gynecologists office rather than requiring expensive laboratory procedures.Under CEO Jonathan Gubspuns leadership,the company has increased fertility treatment access for over 50 million couples and single mothers,raised$560,000 in funding,and expanded its innovations to include a home intrauterine insemination system.Selectivitys work demonstrates how medical innovations can help make fertility treatments more readily available to patients around the world.While many people simply cannot get the treatments they need,medical innovations can bridge that gap and ensure that everyone has medicine.Treatments need to be practicable to be possible.Even when people can obtain the equipment and medicines necessary for treatments,those treatments are often too difficult to use effectively.Complicated medication regimes,sophisticated equipment,and opaque methods of use pose substantial risks to patients,especially in regions with particularly low doctor-patient ratios.Medication non-adherence is a significant global health issue,with patients in developed nations taking their medications properly only about half the time.This failure of compliance leads to reduced drug efficacy,increased hospitalization rates,and antimicrobial resistance.2 To address this,Dr.Wedyan Babatain at King Abdullah University of Science and Technology(KAUST)is addressing the challenge through her patented wearable medical device technology,which uses flexible graphene to create comfortable,skin-conforming devices that can monitor,diagnose,and automatically administer medications.This innovation is particularly significant because it can be manufactured using accessible techniques such as 3D printing,making it viable for low-resource settings,where medication non-adherence is a particularly high risk.Innovate4Health 6 Especially with KAUSTs robust technology-sharing programs,Dr.Babatains invention represents how innovations can make medical treatments more easily usable by anyone and everyone.Even modern medicines leave room for improvement.Medical treatments are often less effective than we would like,as well.While the days of humors and bloodletting are gone,many modern therapies are often just as brutal for the patients who rely on them.Traditional cancer treatments like chemotherapy and radiotherapy come with severe side effects,damaging healthy cells alongside cancerous onesfrom organ toxicity and hair loss to bone marrow suppression and radiation sickness.3 Too often,cancer treatments are a simple matter of hoping that the cure is less dangerous than the disease.Chilean startup Andes Biotechnologies offers a promising alternative through its drug Andes-1537,which uses“antisense”technology to precisely target cancerous cells by their unique genetic sequences while leaving healthy cells unaffected.This more-targeted approach could revolutionize cancer treatment by eliminating the harsh side effects of conventional therapies,and potentially treat all forms of cancer.Thanks to patent protections that helped secure$10 million in funding,the company has advanced through FDA clinical trials,bringing this gentler and more-effective treatment option closer to patients who currently face limited choices between aggressive therapies or none at all.Bridging that gap illustrates just how important it is to ensure that we continue to improve on existing treatments,in terms of both greater efficacy and lesser side effects.Personalized medicine is an opportunity to more effectively meet a patients needs.Logistical challenges to healthcare are often met with simple numbers,especially in a global settingif we mass-produce enough pills,surely we can medicate the whole world.However,good medicine is not one-size-fits-all,and it is dangerous to assume so.Modern technology provides an invaluable opportunity to tailor treatments to individual patients.Colombian company Smartbone,led by engineer Catalina Isaza,has revolutionized craniofacial implant treatment by developing a patented ceramic-polymer compound that can be customized to each patients unique needs.Unlike traditional titanium implants,these personalized prosthetics not only cost one-third less than imported options but also better resemble natural bone,promote bone growth,and can be precisely shaped to restore both function and aesthetics for each individual patient.This personalization is particularly valuable for treating the diverse range of craniofacial injuries and congenital defects that affect millions worldwide,from accident victims to children born with conditions like cleft palate.Through a strategic partnership with distributor Innmetec,Smartbone has already provided customized treatment to hundreds of patients in Colombia and is expanding across Latin America,demonstrating how individualized medical solutions can improve patient outcomes while reducing costs and wait times.The global disease burden is shifting toward non-communicable diseases.As life expectancy increases worldwide and communicable diseases are gradually eliminated,humans begin to live long enough to suffer from a host of non-communicable diseases that were previously rarer.As healthcare 7 burdens shift to reflect this change,it becomes increasingly important to enable healthcare systems to better handle this growing non-communicable disease burden.Leukemia,which affected nearly 475,000 new patients globally in 2020 and caused over 311,000 deaths,presents a significant healthcare challenge that is further complicated by widespread drug shortages.4 This is particularly worrisome in countries like Saudi Arabia,where all major oncological institutions report treatment disruptions affecting patient care.Saudi Arabian researcher Asma Saeed Al-Amoodi has developed a promising solution through her patented innovations in blood stem cell treatments at KAUST.Her breakthrough involves improving the efficacy of bone marrow transplants by enhancing blood stem cells ability to target and graft to affected areas,potentially offering a more-reliable treatment option for leukemia patients who currently face uncertain outcomes even with successful transplants.Al-Amoodis innovations are attracting the funding and recognition needed to develop these treatments further,demonstrating how healthcare innovation can help advance solutions for complex noncommunicable diseases.Global pandemics such as COVID-19 present unique challenges to healthcare.The coronavirus presented a wholly unanticipated global challenge in the last several years,and many regions struggled to manage the pandemic.Fortunately,many local innovators found novel solutions to combat a novel disease.For example,while traditional medicines are often dismissed as unscientific,they are vastly more readily available to rural populations than many blockbuster drugs,which can be lifesaving during a global pandemic.Traditional medicines also have historically informed many modern medical treatments,with two-fifths of modern pharmaceuticals having roots in traditional practices.5 Herbanext Laboratories,a Filipino drug manufacturer founded in 2001,exemplifies how traditional medicine can be modernized through scientific research.The company has successfully standardized herbal extracts for medicinal use,most notably developing a refined medicine from the tawa-tawa herb that has proven effective against both dengue fever and COVID-19 symptoms.The companys work demonstrates how investment in pharmaceutical R&D can improve traditional medicines through clinical trials and standardization,while simultaneously promoting biodiversity conservation and economic development in regions rich in natural resources such as the Philippines.This grass-roots approach to healthcare is especially important in handling COVID-19 and other such diseases that severely test supply chains,resources,and international collaboration.Healthcare faces many problems,but human ingenuity is inexhaustible.We have found that while healthcare challenges vary widely,there are nevertheless patterns that emerge.We have grouped these case studies based on what challenges people face,both to illustrate how many different solutions people devise and to emphasize the common ground that humanity shares in its struggle for physical wellbeing.Innovate4Health 8 Among the diverse challenges addressed here are:Removing practical barriers to accessing treatments;Simplifying treatments and diagnostics to make it easier for patients to access and use them;Increasing efficacy and removing the detrimental side effects of existing therapies;Making personalized medicine accessible to more patients;and Reducing the global burden of non-communicable diseases as life expectancy increases.We hope that this report will contribute to a better understanding of the importance of IP-driven innovation in meeting global health challenges.9 Chapter 2:Challenge:Removing Practical Barriers to Accessing Treatments NIRAMAI Thermalytix:Transforming Early Breast Cancer Detection in India By Natalie Khoo Breast cancer looms as a silent threat to millions of women globally,affecting approximately one woman every 14 seconds,somewhere across the world.6 With the increasing incidence of breast cancer,the global cancer burden is only likely to increase,especially in low-income countries such as India.While early breast cancer diagnosis through mammography screening programs is crucial to reducing the breast cancer burden,women in India are 50 percent less likely to be diagnosed early with breast cancer than women in high-income countries.7 This is underscored by Indias three-year breast cancer survival rate of 68 percent,as compared to the global average of 84 percent.8 Amidst Indias breast cancer crisis emerges NIRAMAI Thermalytixa novel artificial intelligence(AI)-based medical device that detects breast cancer at a much-earlier stage by utilizing patented machine learning algorithms to analyze thermal imaging data(Patent numbers:US 9898817,US10307141,US10055542,US9622698).9 NIRAMAI,which stands for“Non-Invasive Risk Assessment with Machine Intelligence,”is at the forefront of highlighting the transformative role that IP can play in the healthcare innovation field in low-income countries with its patented technology called Thermalytix.To date,NIRAMAI has been granted 33 Innovate4Health 10 patents,including 11 in the United States and others across Europe,India,Japan,and Singapore as well as Canada to ensure the companys IP is widely protected.10 The World Health Organization(WHO)recommends a doctor-patient ratio of at least 1:1000one doctor per 1000 patientsto ensure adequate healthcare coverage.In India,however,this ratio is significantly lower,with only 0.74 doctors per 1,000 patients,in contrast to the top 10 GDP-ranked countries.11 The team at NIRAMAI,under the leadership of CEO Dr Geetha Manjunath addressed this problem through an innovative approach.By offering an automated and portable cancer screening tool that can be easily operated in any clinic,even by low-skilled personnel,NIRAMAI Thermalytix demonstrates the ability to provide essential breast cancer screening services to women of all ages in resource-constrained environments where mammography screening is not feasible.12 Since its launch,NIRAMAIs low-cost medical device has helped more than 100,000 women across India and globally by enabling early screening for breast cancer.It is able to reduce diagnostic costs by approximately 95 percent compared to traditional screening methods.13 Moreover,NIRAMAI Thermalytixs radiation-free approach,combined with its non-invasive and painless imaging method,also makes breast cancer screening a comfortable and pain-free experience,as opposed to traditional mammography,which can cause discomfort or pain for some individuals.Similarly,the patented technology of Thermalytix not only provides affordable,reliable,and high-precision breast cancer screening services,but also ensures timely detection,as it can detect significantly smaller tumors(2cm)than those that can be detected through clinical breast examination and the whole process takes only 10 to 15 minutes.14 NIRAMAI Thermalytixs success has attracted significant financial backingthe company has raised a total of$7 million from institutional investors in India,Japan,and Singapore,such as Dream Incubator,pi Ventures,and Ankur Capital,just to name a few.15 The Bill&Melinda Gates Foundation and numerous others have acknowledged the value of the innovation,and awarded the inventors funding to continue research,development,and deployment of their innovation.16 Additionally,with its U.S.Food and Drug Administration(FDA)approval in 2022,NIRAMAI became the first Indian company to receive both European Medicines Agency(EMA)and U.S.FDA clearance for a medical device used for women health,marking a significant milestone in the healthcare companys journey as it enters the lucrative US market.17 In addition to its application in breast cancer screening,NIRAMAI has also employed its technology to respond to the COVID-19 outbreak by introducing“FeverTest.”This device combined NIRAMAIs most-awarded novel AI solution,Thermalytix,with a thermal camera to detect elevated temperature(fever).18 This further highlights the pivotal role of IP protection,as NIRAMAIs patented technology was able to quickly adapt its technology to an urgent health crisis,amplifying community screening and complementing Indias national response to combating COVID-19.Intellectual property rights have played a significant role in bringing NIRAMAI Thermalytix to market.According to CEO Manjunath,“patenting has become a way of life,”emphasizing the importance of protecting innovative ideas.19 She advocates for startups to leverage government initiatives such as fast-tracking,reimbursement of application fees(with caveats),filing under the Patent Cooperation Treaty(PCT),thorough scrutiny of Non-Disclosure Agreements(NDAs),and access to research grants.20 This underscores the significant role of patents in enhancing the value of a startup and supporting innovative health solutions.11 NIRAMAI Thermalytixs success has demonstrated the great potential for improving early breast cancer detection in low-income countries such as India.This advancement in breast cancer screening technology is crucial,especially in low-resource settings where organized mammography screening is not feasible due to factors such as affordability,limited healthcare access in rural and remote areas,infrastructure constraints,and shortage of healthcare providers.21 NIRAMAI Thermalytix has shown promise in bridging the gap in breast cancer diagnosis and ultimately saving lives.Its technology and the IP embedded within represent one important piece of the larger policy puzzle that affects healthcare outcomes in low-income countries.Innovate4Health 12 From Plants to Patients:How Intellectual Property Propelled La-Africa Soothers Natural Approach for Pain Relief By Natalie Khoo Its no secret that sports and physical activity offer a myriad of health benefits for both physical and mental well-being.From shielding against heart attacks to alleviating stress,the positive effects of engaging in physical activity cannot be overstated.However,there is also an inherent risk of musculoskeletal injuries,particularly joint injuries and post-traumatic arthritis,a condition that causes stiffness and pain around joints.22 This risk is particularly pronounced among athletes,sports,and fitness enthusiasts,who subject their joints to significant wear and tear compared to the average individual.Post-traumatic arthritis impacts more than 5 million people every year,accounting for approximately 12 percent of all osteoarthritis cases.23 This condition occurs most commonly in the knees,hips,lower back,the neck,small joints of the fingers,and the base of the thumb.Despite rapid advances in biomedical engineering,addressing bone and cartilage repair in joints after an injury remains a great challenge in the field of regenerative medicine.This challenge has always been of particular interest for Professor Keolebogile Shirley Motaung,Director of Technology Transfer and Innovation at Durban University of Technology in South Africa.24 Witnessing her mothers struggle with the chronic pain associated with osteoarthritis and the weaknesses of the South Africa healthcare system to provide adequate care,Professor Motaung was determined to find a way to alleviate the suffering that patients with musculoskeletal injuries have to endure.In 2015,Professor Motaung founded Global Health Biotech(Pty)Ltd.,a spin-off company based in South Africa.25 Drawing upon South Africas rich biodiversity and long history of indigenous communities use of 13 medicinal plants to treat various kinds of illnesses,the team at Global Health Biotech Pty Ltd.created La-Africa Sootheran innovative plant-based anti-inflammatory cream made from African teak,a tree of woodlands and savannahs,and the pineapple lily,a short,showy flower.26 These plants contain compounds that can activate body cells,promote bone formation,and facilitate wound healing.When combined with stem cells,they guide the growth of new tissues,in a process known as scaffolding.In low-and middle-income communities all across the world,financial and structural barriers often prohibit individuals from assessing essential bone and cartilage treatments such as bone morphogenic proteins,primarily due to their high costs,and South Africa is no exception.27 La-Africa Soother emerges as a low-cost,safe,and non-invasive alternative treatment for musculoskeletal injuries.28 Unlike other creams targeting muscle aches and joint pains,La-Africa Soother is the first product of its kind aimed at preventative care.29 By applying La-Africa Soother before and after engaging in physical activity,it can reduce the likelihood of anticipated muscle aches.Since this innovative invention is a plant-based anti-inflammatory cream,it also has restorative abilities which are unique to the market.Due to its plant-derived medicinal composition,La-Africa Soother is able to promote the development of collagen type II,the main structural component of the cartilage tissue in joints.30 Intellectual property rights have played an instrumental role to the success of Global Health Biotech(Pty)Ltd.According to CEO Motaung,“From the outset,it was clear that intellectual property would be central to Global Health Biotechs future,”highlighting the foundational importance of safeguarding innovations through patents and other forms of intellectual property to drive innovation forward.31 To date,Global Health Biotech(Pty)Ltd.has secured patents from the European Patent Office(80298/Munich,Germany:18836901.3-112)and South Africa:(2017/08330).32 As a company dedicated to providing high-quality and affordable plant-based products,La-Africa Soother has helped individuals suffering from chronic joint and muscle pain associated with musculoskeletal injuries in areas with inadequate access to essential medical products.Global Health Biotech(Pty)Ltd.has demonstrated the importance of effective intellectual property rights and trademark protection in the development and commercialization of its own brand and services.33 Additionally,intellectual property rights empower innovators to increase their impact by partnering with local research universities.As Professor Motaung highlighted,“The fact that the Durban University of Technology covered our patent fees,and that I have been able to license it at a much lower cost,has really assisted our business.”34 Building on this success,Professor Motaung is currently working to include intellectual property training in the curricula for the universitys science degrees.35 By doing so,she aims to cultivate a new generation of innovators and business leaders,equipping them with the tools to bring their ideas to market successfully.In addition,she advocates for universities to not just hold onto their intellectual property rights but to actively“license those patented technologies,”ensuring that valuable innovations are not left dormant,but are instead utilized to benefit society and contribute to economic growth.36 Since the launch of La-Africa Soother,Global Health Biotech(Pty)Ltd.under the leadership of Professor Motaung,has garnered numerous awards,including the Strategic African Women in Leadership(SAWIL)Trailblazers Award for 2022/2023 and was honored as top innovator in the Chancellors Awards under Impactful:Collaborative Entrepreneurial Project between Technology Transfer&Innovationto name a few.37 Also,the World Intellectual Property Organization(WIPO)has acknowledged the value of the innovation,as it was featured in the WIPO Development and Intellectual Property Committee project Innovate4Health 14 on Increasing the Role of Women in Innovation and Entrepreneurship,Encouraging Women in Developing Countries to Use the Intellectual Property System.38 La-Africa Soothers story has illustrated how intellectual property can transform innovative ideas into life-changing solutions in the healthcare field.It is a testament to the important role intellectual property and collaborative partnership play in driving innovation forward especially in low-income countries.15 Herbanext Laboratories Turns Traditional Medicine Into Modern Healthcare By Douglas Park Though sometimes dismissed as unscientific,traditional medicine can offer substantial therapeutic value.As noted by the WHO,however,traditional medicines can be dangerous in many contexts because these medicines lack the research and testing necessary to prove that they are both safe and effective.Traditional medicines can also provide a foundation for further drug development,especially for other diseases and conditions,but incentives to invest in exploring such new uses are lacking.Herbanext Laboratories,a Filipino drug manufacturer,leads the charge in not only testing drugs derived from native plant life but also in discovering and developing invaluable new applications for them.39 Traditional medicine typically lacks much of the regulatory oversight that applies to other drugs to ensure their safety and efficacy,but centuries of experience also can provide evidence of safety and efficacy.Rather than simply dismissing these practices,many pharmacologists have discovered that they instead can leverage ancient and indigenous medicinal practices to inform modern medicine.For example,the use of vaccines is a direct descendant of variolation,a practice of intentionally exposing patients to smallpox that was used to treat smallpox for thousands of years.40 The principle of inoculation has been foundational to medicine almost as long as humans have practiced healthcare.Fully two-fifths of modern pharmaceuticals were developed from traditional medicine in some capacity,from aspirins Sumerian roots to refining opium into morphine.41 It is therefore vital that groups like Herbanext work to refine these treatments to ensure their safety and efficacy.Herbanext Laboratories began in 2001 with cultivation and processing of medicinal reishi mushrooms.They shifted to extraction and spray-drying in 2011 with funding from the Philippines Department of Science and Technology(DOST),soon after becoming one of the largest suppliers of herbal ingredients in the country.Herbanext proudly claims the title of the first Filipino company to standardize the production of herbal extracts for medicinal use,a very important step in ensuring that patients receive safe and effective doses of these traditional medicines and that they do not contain dangerous impurities.In 2019,Herbanext announced the availability of a refined and concentrated medicine made from the tawa-tawa herb,also known as Euphorbia hirta.42 Tea made from the tawa-tawa herb has been used for centuries to fight dengue,and recent research indicates that the herb has antiviral and pro-platelet properties.After the Filipino Department of Health announced a national dengue epidemic,Herbanext created a tawa-tawa-based Innovate4Health 16 herbal supplement to be administered in precisely modulated capsule form.Herbanext notes that this formulation offers a much more targeted and effective treatment than the traditional but inexact method of brewing tea.Furthermore,when the COVID-19 pandemic broke out in 2020,it turned out that Herbanexts tawa-tawa extracts could treat more than just dengue.In March of 2021,the University of the Philippines Visayas,Corazon Locsin Montelibano Memorial Regional Hospital,Philippine Red Cross of Manila,Quezon Institute,and DOST began clinical trials to test Herbanexts tawa-tawa medicine as an adjunctive treatment for COVID symptoms.43 In late 2021,trials confirmed the use of tawa-tawa to treat COVID symptoms,and DOST began additional research and testing to meet Filipino FDA standards for“effective against COVID”labeling.44 DOST has stated that these additional treatments were invaluable for many Filipino citizens,for whom more popular drugs like remdesivir or tocilizumab were both hard to find and prohibitively expensive.As a result,less-wealthy patients have often relied heavily on the accessibility and affordability of traditional medicine such as Herbanexts products,especially after the 2004 Proclamation No.698 that made proven traditional medicine available through the national healthcare system.None of this would have been possible without Herbanexts dozens of patents,of course.45 While traditional medicine itself is generally unpatentable,the improvements that Herbanexts researchers have made present substantial advancements in the efficacy of these treatments.The clinical trials necessary to ensure the safety and efficacy of these drugs are expensive,however,and it is only with the funding enabled by patent protections that Herbanext has been able to prove the value of its products and make them available to people across the Philippines.This process also illustrates how patents promote iterative innovation.If companies like Herbanext were unable to secure patents on incremental improvements like their herbal extractions,then they would have neither the means nor incentive to make those improvements.It is because of the patents that Herbanext and others can turn inconsistent and unregulated herbal teas into tested and proven medicines that can save lives.These innovations also foster greater cultivation of native biodiversity,which provides both socioeconomic and ecological benefits.The Philippines has 32,000 species of terrestrial flora and fauna and 10,000 aquatic species,and yet the nation derives less annual value from its biodiversity than it does from exploitative industries like fishing,mining,and forestry.46 Philip Cruz,founder of Herbanext Laboratories,says that“Biodiversity is the Philippines most underutilized economic resource,”and that the cultivation necessary to fully leverage that resource will also benefit conservation efforts.Instead of conventional monoculture farming,diversification will strengthen the indigenous ecosystem and provide a reliably broad portfolio of renewable natural resources.Modernization of traditional agriculture and medicine provides comprehensive socioeconomic benefits,but it is only possible through robust intellectual property protections.By maintaining a patent system consistent with international standards,the Philippines is well on its way to becoming one of the largest innovation economies in the world.17 Selectivity Life,Harnessing Innovation to Expand Access to Fertility Treatments By Natalie Khoo Infertility,commonly defined as the inability to achieve a pregnancy after 12 months or more of regular,unprotected sexual intercourse,is a pressing global health issue.47 Estimates suggest that infertility impacts 48 million couples and 186 million individuals of reproductive age worldwide,often with devastating consequences.48 According to Dr.Tedros Adhanom Ghebreyesus,Director-General at the World Health Organization(WHO),this disease of the male and female reproductive system“does not discriminate”and approximately one in six people have experienced infertility at some stage of their lives.49 Beyond responding to declining birth rates,addressing infertility is crucial for upholding individuals sexual and reproductive health and rights(SRHR).However,infertility policies and services in many countries fall short of adequately addressing this pervasive issue.This shortfall can often be attributed to restrictions on individuals ability to access essential services they need,such as assisted reproductive technologies(ART).The global demand for ART solutions to infertility continues to grow,with a market size valued at$25.7 billion.In the United States alone,approximately 238,126 patients had 413,776 ART cycles in 2021,which accounted for 2.3 percent of all infants born in the country that year.50 While there have been significant advancements in fertility treatments,such as in vitro fertilization(IVF),which have revolutionized the notion of human reproductive potential,access to these innovative scientific technologies is still largely unavailable,inaccessible,and unaffordable to many,particularly in low and middle-income countries.Currently,75 percent of individuals affected by infertility worldwide lack adequate access to treatment due to financial barriers,a shortage of trained personnel,or simply a lack of necessary equipment and infrastructure.51 As fertility treatments are predominantly funded out-of-pocket,it often places a significant financial burden on individuals and families residing in low-and middle-income countries.Reports estimate that a single IVF cycle can range from$15,000 to$30,000,underscoring the enormous financial strain associated with seeking care Innovate4Health 18 and the persistent challenge of ensuring equal and equitable access to fertility care,particularly in low-and middle-income countries.52 The team at Selectivity Life,a medical startup based in Argentina,has tackled this global health challenge head-on by redefining what accessible,affordable,and most importantly,inclusive innovation in fertility care looks like.53 By leveraging the companys patented technology(Patent numbers:AU2024201489,CA3053877,US20200032199,WO2018154169)a biomimetic membrane for sperm selectionthe innovators at Selectivity Life created an innovative sperm selection device that shifts traditional paradigms of laboratory-based fertility treatments to a more convenient and patient-centered approach.54 Unlike current infertility treatments,Selectivity Lifes innovative medical solution is non-invasive and allows procedures to be conducted right in the comfort of an obstetrician gynecologists office,ultimately simplifying the journey toward conception,making the process more accessible and less daunting for those involved.The patented technology enables efficient and effective sperm selection by mimicking the natural physiological barriers sperm must navigate to fertilize an egg,thus ensuring DNA fragmentation is kept at a minimum,increasing the likelihood of successful conception.55 This approach not only improves the quality of sperm used,but also eliminates the need for costly and complex medical procedures and equipment,reducing the financial strain and emotional stress patients must endure,especially in resource-constrained environments.56 Selectivity Life has made a tremendous impact in the current infertility treatment landscape.Under the leadership of founder and CEO,Jonathan Gubspun,the company has successfully increased access to fertility treatments for over 50 million couples and single mothers who previously faced substantial barriers to accessing ART.57 Similarly,the startups success has attracted significant financial backing from Crdoba Innovation and Entrepreneurship Agency and CITES,an accelerator and technology-based business incubator of early scientific-technological projects.58 Notably,the company has managed to raise a total of$560,000 to fuel further development and expansion of Selectivity Lifes medical innovation portfolio.59 The value of the innovation has also been recognized on a global scale as Selectivity Life was one of the three startups from Argentina that were chosen as the finalists for the Entrepreneurship World Cup in 2023,marking a significant milestone for the health startup.60 The role of intellectual property cannot be understated,especially in this space.For startups like Selectivity Life,securing patents is crucial in ensuring they maintain a competitive edge in the market.Moreover,it provides them with the leverage needed to negotiate partnerships and funding,which are crucial for scaling operations and expanding their impact on global health challenges.The profound impact of Selectivity Lifes intellectual property is evident in the expansion of their product range.Building on the success of the patented technology in the sperm selection device,the team created a home intrauterine insemination(IUI)system,a single device that allows IUIs to be conducted in the comfort of ones home.61 Designed for simple and easy use,this user-friendly solution offers a significant improvement in the quality of life for individuals struggling with infertility.As fertility management strategies are deeply personal journeys that vary widely from one individual to another,Selectivity Life offers a range of options tailored to meet the diverse needs and circumstances of those aspiring to start or grow their families,as the debilitating nature of infertility not only affects physical health but also inflicts significant emotional and mental stress.The success of the team at Selectivity Life has not only demonstrated the critical role of innovation and intellectual property in addressing global health challenges but also serves as a beacon of hope for millions of individuals suffering from infertility.19 MScan Uganda is Advancing Maternal Healthcare and Driving Social Impact Through Its Innovative Portable Ultrasound Technology By Natalie Khoo Improving maternal mortality was one of the 17 Sustainable Development Goals(SDGs)adopted at the 2015 Sustainable Development Summit.Specifically,SDG 3.1 aims to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.62 This underscores the urgent need for innovative maternal healthcare solutions,particularly in low and middle-income countries such as Uganda,where maternal mortality remains alarmingly high.According to the World Health Organization,more than 800 women die every day from pregnancy-related complicationsmeaning that a woman dies approximately every two minutes.63 This is particularly concerning as 95 percent of all maternal deaths occur in developing countries and are often due to preventable causes resulting from conditions such as amniotic fluid deficiencies or umbilical cord complications that could be identified and managed with timely and proper medical diagnostics.64 While obstetric ultrasound is an integral component of prenatal care and is a common tool used in high-income countries,it remains largely unavailable in sub-Saharan Africa.Sixty percent of women in sub-Saharan Africa go through their entire pregnancy without the benefit of a single ultrasound examination,exacerbating the disparity in maternal health outcomes between developing and developed countries.65 Similarly,the lack of access to this vital diagnostic tool contributes to the regions high perinatal mortality rates,which are approximately 10 times higher than those in high-income countries.66 For example,in Uganda,the stillbirth Innovate4Health 20 rate is 17.8 per 1000 live births which is significantly higher than the global average of 13.9 per 1,000 live births.67 Recognizing the need to bridge this gap,MScan Ugandacofounded by Dr.Ahimbisibwe Prosper,Phyllis Kyomuhendo,Menyo Innocent,and Nasasira Ivanemerged as a pioneering initiative to address the maternal health challenges faced by pregnant mothers living in rural communities throughout Uganda.68 Driven by the urgent need to curb the high maternal mortality rates through early detection and effective medical intervention,the team created MScan,a patented,low-cost,portable ultrasound probe that connects to a phone or laptop to provide an affordable sonogram to pregnant mothers in rural Africa(Patent numbers:UG U/2018/000008,UGP/2019/000006).69 This innovative device brings advanced prenatal care within reach of those who need it most.By utilizing piezoelectric crystals and digital signal processing chips to send out and receive ultrasound waves,MScans technology has effectively miniaturized the size of a traditional ultrasound machine,reducing it from a large,bulky device to a pocket-sized probe that can easily connect to a laptop or phone preloaded with the MScan app to display the image in real time.70 Unlike competitors such as Clarius Health and Philips Lumify,MScans device connects via USB port 2.0 and above,making it compatible with a wide range of devices.71 Thus,this compact and portable design allows healthcare providers in remote areas to conduct detailed ultrasound examinations with minimal resources,overcoming the infrastructure challenges often faced in these regions.In addition,MScans affordability is what sets it apart from other devices on the market.The cost of an MScan probe,complete with a smartphone or laptop,is around$2,500nearly one-tenth of the price of traditional ultrasound machines,which can range from$15,000 to$20,000.72 This significant reduction in cost makes advanced prenatal care more accessible to underserved communities,thereby bridging the gap in maternal healthcare services.Furthermore,MScan partners with private medical facilities to offer ultrasounds at an affordable rate of only$2 per session,compared to the$10 typically charged in some private hospitals.According to Dr.Ahimbisibwe,this pricing model ensures that essential diagnostic services are more accessible to mothers while also contributing to the financial sustainability of the facilities.73 Since its inception in 2017,MScan has made a significant impact on maternal healthcare in Uganda.To date,the initiative has performed over 3,000 ultrasound scans,detecting more than 1,500 complications.74 Notably,20 percent of these scans identified complications that led to timely referrals for medical and surgical interventions.75 Besides,the team is also focused on empowering and training local health workers to use the technology effectively.This is demonstrated by the companys effort in conducting over 25 training sessions and 10 medical camps held.76 The companys commitment to social impact and equitable healthcare access has also made headlines on various prestigious platforms.The teams dedication was highlighted when they were featured in MIT Solve,showcased in the Africa Innovation Challenge 2.0 by Johnson&Johnson,and honored with The Builders of Africas Future 2022 Award by the United States Africa Development Foundation.77 They also triumphed at the TechCrunch Startup Battlefield Africa,where their innovative approach and potential for significant impact were celebrated.78 MScans motto,Save a Mother,Save a Life,”is evident in every aspect of its work.As MScan continues to grow and innovate,its focus remains on scaling its efforts to reach more underserved communities.The team aims to expand the companys impact by increasing the number of scans performed,further training local health 21 workers,and enhancing the affordability and accessibility of their technology.MScans commitment to bridging the healthcare gap in East Africa reflects a broader vision of equitable healthcare for all,making a profound difference in the lives of countless mothers and children.Innovate4Health 22 Chapter 3:Challenge:Simplifying Treatments and Diagnostics to Make It Easier for Patients to Access and Use Them Seeing Is Believing:FOODVICAs Innovative Non-Surgical Cataract Treatment By Kristen Thompson Imagine trying to see the outside world through a frosted window.Thats what life is like for millions of individuals with cataracts,one of the leading causes of preventable blindness worldwide.79 While cataract surgery is highly effective,the procedure itself is not always readily available.To address this issue,Mexican company Foodvica has developed a new way to treat cataracts with medication,as a cutting-edge,non-invasive option.In Mexico,inadequate surgical and healthcare resources impose significant challenges in treating cataracts.Research suggests that a substantial portion of ophthalmologists do not have the resources necessary to perform cataract surgery.80 Despite having approximately 5,000 ophthalmologists,Mexico struggles to address the healthcare needs of the population,with one million individuals lacking access to essential surgical procedures.81 This is particularly concerning for Mexicos rapidly aging population,who are experiencing an increasing incidence of cataracts with advancing age.Projections indicate that by 2020 nearly 20 percent of the population,or approximately 23 million individuals,will be over the age of 50.82 Risk of cataract formation also includes factors such as obesity and diabetes,and Mexico has one of the highest diabetes and obesity rates in the world.83 In addition,a 2015 Manatt Jones study revealed that cost is the primary barrier to cataract surgery in Mexico,with the operation inaccessible to 40 percent of patients.84 Mexico spends a good deal less of its gross domestic product(GDP)on health care than the average among other countries,leaving patients to pay almost half of their health care costs out of their own pockets.Frequently long waiting lists for surgery further stall cataract surgery.85 To address these challenges,Labcymo,a division of Mexican company Foodvica,has developed a non-surgical,nanotechnology-based treatment for cataracts.86 Their formulation promises an affordable and accessible solution for patients at all stages of cataract development,potentially transforming the landscape of cataract care worldwide.Previous attempts to develop non-surgical cataract treatments have shown little promise,requiring regular application of several large doses of medication.87 By contrast,Labcymos novel combination of known 23 therapeutic compounds have demonstrated significant potential in treating certain types of cataracts with relatively few and small doses.88 Labcymos treatment also makes use of smaller particles of the active ingredient,allowing greater absorption and distribution in a patients eye.Given that the treatment works by applying bioactive compounds to break down and decrease the buildup of proteins that cloud the eyes,Labcymos greater permeation increases the overall effectiveness of the treatment.89 While Labcymo plans to offer its treatment for cataract patients around the world in the near future,it is still in the early stages of testing.Gaining regulatory approval for new medical treatments typically requires clinical trials that can take many years and hundreds of thousands or even millions of U.S.dollars.It is not easy to attract this much investment for testing,however.Labcymo has decided to develop its cataract treatment for veterinary use first,not only to show how effective the medication is but also to secure funding for the considerably more expensive clinical trials needed for human use.Testing and other development costs for veterinary use are routinely only a fraction of those for human use.90 Regardless of whether testing a pharmaceutical for human use or veterinary use,however,companies would not be able to afford to invest in the intensive testing needed for regulatory approval without the protection of intellectual property rights.Patents in particular provide inventors such as Labcymo with the rights to keep others from making,using,or selling their inventions.Without patent rights,by contrast,competitors might copy not only others inventions but their investments in developing those inventions.Patents are therefore vital in protecting investments in inventive new technologies,such as testing new treatments in order to grain regulatory approval to market them.Labcymos commitment to developing it cataract medication is evident in its patent applications not only in Mexico but also in other countries.Labcymo has filed applications through the PCT,under which innovators can seek patent protections in multiple countries through a coordinated process.91 In this way,Labcymo can more easily bring its cataract medication to patients in many different countries without fear of losing the hard work,time,and money that it has put into its innovative treatment.In turn,these essential protections will enable Labcymo to continue developing its groundbreaking work into a new and more readily accessible non-surgical alternative for those who otherwise might not be able to receive treatment for their cataracts.Innovate4Health 24 Wearable Respiratory Rate Monitoring Glove:A Breakthrough in Childhood Pneumonia Detection in Bangladesh By Krishna Sankya Talluri Pneumonia is a curable and mostly preventable lung disease,with a mortality rate of only 1 to 3 per 100,000 children in high-income countries,and generally is not perceived as a serious public health concern.92 Pneumonia nonetheless has a disproportionate effect on children in low-and middle-income countries(LMICs)because pneumonia often goes undiagnosed and untreated until children in those countries are already severely ill.93 In 2019 alone,pneumonia accounted for 14 percent of childrens deaths globally,with most of those deaths occurring in economically weaker communities.To address this disparity,University of Edinburgh academic Dr.Srinjoy Mitra led a multinational team to devise a convenient,versatile,and affordable device that a user can literally wear in the palm of their hand to diagnose cases of childhood pneumonia.This device could significantly improve early diagnosis and treatment in countries such as Bangladesh,where access to larger,more-expensive diagnostic and monitoring equipment is very limited.Bangladesh is a quintessential example of an LMIC that has consistently struggled to curb the impact of pneumonia.In 2018 alone,pneumonia claimed the lives of more than 12,000 Bangladeshi children,accounting for approximately 13 percent of all mortalities among children under 5 years of age.94 A large part of the problem with identifying and treating children with pneumonia early enough is the lack of reliable diagnostic equipment.In LMICs like Bangladesh,health care providers must instead rely on much more subjective clinical indicators such as coughing and increased respiratory rates.95 These care providers often must measure a childs number of breaths per minute manually using watches,timers,or abaci.96 Measuring respiratory rate visually demands intense focus and can be particularly challenging if the child is moving,crying,or breathing rapidlyall of which are likely in a sickly child.To tackle this issue,Dr.Srinjoy Mitra led a dedicated team of researchers at the University of Edinburgh to develop the Multi-Modal Portable Respiratory Rate Monitoring Device for Childhood Pneumonia Detection Device,a small and easily portable diagnostic device that can be worn as a glove.97 This project is groundbreaking because it does not require expensive equipment such as X-rays or blood tests for diagnosis and allows doctors to treat childhood pneumonia earlier and more successfully.Dr Sadeque Reza Khan,a Bangladeshi national working in Edinburgh,is the lead author of this paper.25 The rechargeable prototype of the diagnostic device comprises two primary components:simple hardware and a cloth glove.The glove has textile electrodes on the palm and fingertips and a printed circuit board on the back.The textile electrodes measure bio-impedance caused by respiration while the accelerometer monitors the patients breathing.The device transmits this data to a mobile app via Bluetooth,allowing healthcare professionals to assess the data remotely.The electronic components are even detachable,allowing the user to wash the glove separately or even replace it altogether.This flexibility ensures reusability and helps prevent infection.Initial tests of the glove design done in collaboration with the University of Dhaka in Bangladesh have successfully demonstrated high accuracy as well as capacity,with battery life allowing uses up to 60 to 70 times a day.The research team next plans to expand the devices capabilities to other diagnostic methods such as electrocardiograms.Dr.Mitra and Dr.Khan do not yet have published patents on this device,but it is likely that the possibility of patent rights was essential to securing funding for the project.The University of Edinburgh,this projects primary sponsor and a staunch supporter of knowledge sharing and licensing of IP in less wealthy nations,also stresses the importance of commercializing and distributing new health-related technologies such as Dr.Mitras diagnostic glove.98 Though human wellbeing is an essential motivation,investors like the University of Edinburgh recognize the need to secure substantial investments in demonstrating the safety and efficacy of new technologies before they can be marketed in developing countries.Patent rights provide that security and offer development and marketing leverage for new products.One option for securing patent rights is the PCT system,but the PCT relies on individual nations having robust domestic IP systems.Though it is not yet a member of the PCT,Bangladesh has been striving to position itself globally as an IP-rights-friendly nation.The recent Bangladesh Patent Act of 2022 is emblematic of these efforts.99 The Act is designed to ensure compliance with the Trade-Related Aspects of Intellectual Property Rights(TRIPS)Agreement and other international standards.100 For example,the Bangladesh Patent Act extended the patent protection period from 16 years to 20 years,consistent with terms in most nations.101 It also establishes a concrete judicial system for handling patent cases and a comprehensive list of relief options for patent holders,improving the administrability and efficacy of patent rights.102 The average cost to process a patent in Bangladesh,including processing and attorneys fees,sits between$1,000 and$3,000 for most inventions.103 This is significantly cheaper than costs in the United States and United Kingdom,where filing costs average at$10,000,making Bangladesh an attractive destination for inventors looking for economical patenting solutions.104 It is highly likely that by obtaining patent rights Dr.Mitra and his team can continue to innovate,attract more investments,and promote wider dissemination.Dr.Mitra continues to develop the project with the help of Dr.Khan,now of Heriot-Watt University,and the inter-university collaboration will benefit from the support enabled by IP rights.With endless possibilities ahead,the Multi-Modal Portable Respiratory Rate Monitoring Innovate4Health 26 Device for Childhood Pneumonia Detection has the potential to be a groundbreaking innovation,revolutionizing healthcare and improving the lives of millions in Bangladesh and beyond.Intellectual Property at Work:How Serenox Africa is Improving Diagnostic Testing in Sub-Saharan Africa By Natalie Khoo Sub-Saharan Africa has long been a recipient of health aid,more so than other developing regions.A call to address the regions pressing healthcare needs and challenges has led to significant investments and developmental aid from donors including international organizations,philanthropists,and multilateral institutions.While these efforts have played a significant role in improving health outcomes and reducing mortality rates,the focus has predominantly been on treating diseases perceived as threats to global health security.These include zoonotic viruses and multidrug-resistant bacterial strains,with tuberculosis being just one example.105 As a result,there has been a large emphasis on providing therapeutics such as antivirals,antibiotics,and,in some cases,targeted oncology drugs to curb the spread of such diseases.While treatments have become increasingly available and affordable,they address only part of the problem.A critical,often overlooked component in addressing such health challenges is accurate and accessible diagnostic testing.Robust diagnostic tools are essential for the accurate identification and management of diseases,enabling timely and appropriate treatments.106 Yet these essential diagnostic services remain largely inaccessible to roughly 50 percent of the population in sub-Saharan Africa.107 This is alarming,as the absence of early,precise,and rapid diagnostics can lead to a cascade of negative consequences.As Dr.Tedros Adhanom Ghebreyesus,Director-General of the World Health Organization,stated,An accurate diagnosis is the first step to getting effective treatment,and“No one should suffer or die because of a lack of diagnostic services,or because the right tests were not available,”underscoring the urgent need to bridge the diagnostic gap.108 Besides hindering timely and appropriate intervention for common and potentially curable diseases,the economic ramifications are also very concerning.Delayed diagnoses often lead to more-severe illnesses,resulting in higher 27 treatment costs and extended hospital stays.This not only strains the already overburdened healthcare systems in sub-Saharan Africa,but also undermines the overall effectiveness of international aid efforts.One organization that has risen to the challenge to address the need for accurate and affordable DNA-based diagnostic services in low-and middle-income countries is Serenox UK.109 A social enterprise spin-out of the University of Oxford,SerenOx UK leverages scientific expertise and intellectual property rights to enable the precise and rapid diagnoses of inherited blood disorders,infectious diseases,and early-stage cancers in sub-Saharan Africa.Through patented bioinformatic analysis of liquid biopsies and licensed machine algorithms,Serenox UK analyzes circulating tumor DNA for multi-cancer early detection,including those caused by infections,transforming the field of diagnostic testing in such regions.110 Currently,SerenOx UK holds patents for a noninvasive pre-natal diagnostic test for sickle cell disease in the United States and in Europe(Patent number:US10900081B2,EP2971082A1).111 These patents in the bioinformatics analysis of liquid biopsies and copyrighted machine-learning algorithms allows SerenOx UK to analyze circulating tumor and viral DNA for multi-cancer early detection,including those caused by infections,by simply drawing blood from the patient.112 Similarly,by combining affordable rapid-point-of-care carrier lateral flow testing and non-invasive pre-natal diagnosis of haemoglobinopathies from maternal plasma,SerenOx UK created a comprehensive suite of precise diagnostic tests for the most-common monogenic disease worldwide.113 Moreover,the DNA sequencing data,produced from its patented technology,is analyzed by Serenox UK and made freely available for research purposes.This not only enhances the value of its patents,but also contributes significantly to research and addresses the dearth of data on the African genome,diversifying the genetic data used in biomedical research.Additionally,this enables partnerships with pharmaceutical companies that require such data to develop new drugs and penetrate new markets.Serenox UK has already made a significant impact across the region.According to Professor Anna Schuh,the organization has helped around 1,000 children and adults across Uganda and Tanzania,demonstrating the scalability and effectiveness of its diagnostic approach.Its commitment to improving health outcomes is further illustrated by the organizations involvement in clinical research.Serenox UK has funded and supervised clinical trials enrolling 379 children with Burkitts Lymphoma,a type of cancer that is particularly prevalent in parts of Africa.114 Recognizing the far-reaching effects of Serenox UKs intellectual property and innovative diagnostic technologies,Professor Schuh saw an opportunity to expand the companys services to the rest of Africa.Building on 18 years experience developing genetic tests for blood diseases and cancer,she founded Serenox UKs sister company,Serenox Africa,the first specialized hematology and hemato-oncology clinic and laboratory in sub-Saharan Africa.115 Based in Dar-es-Salaam,Tanzania,the team,led by Dr William F.Mawalla,is now offering low-cost,low-maintenance tests for as little as$10.116 Serenox Africa employs cloud-based data systems that allow remote analysis by experts,eliminating the need to send samples abroad,which can be challenging and costly.117 This innovative approach ensures timely and accurate diagnoses while leveraging global expertise.Moreover,funding from patients who can afford to pay for services enables Serenox Africa to offer testing more widely to those who are unable to pay,ensuring greater accessibility and equity in healthcare.Innovate4Health 28 In addition to providing cost-effective and accessible diagnostics,a key focus of Serenox Africa is building local capacity and ensuring long-term sustainability.In developing countries like Tanzania,clinicians and scientists often lack sufficient knowledge,exposure,and expertise to produce high-quality laboratory test results,to conduct bioinformatics analyses,and to clinically interpret the results,all of which are crucial for a DNA tests quality and accuracy.118 Therefore,to address this gap,Serenox UK provides training to ensure the quality of sample processing in the laboratory and to support data interpretation,effectively amplifying the transfer of know-how.Serenox UK and Serenox Africas vision to ensure that“patient-near,fast,accurate and affordable testing for key treatable diseases are commonly available to all patients in sub-Saharan Africa”is a testament to the vital role IP rights play in addressing global health challenges.119 Its success,rooted in Serenox UKs patented technology,has paved the way for ambitious future plans.These include implementing non-invasive prenatal diagnosis for sickle cell disease into routine prenatal work-up,starting with the UKs National Health Service(NHS),running early cancer detection tests in India,and consolidating Serenox Africas presence in Tanzania.120 29 Dr.Wedyan Babatain Brings Wearable Medical Tech Closer Than Ever By Douglas Park Wearable technology,such as smart watches,provides an opportunity to materially increase the ease of use of many medications,improving in turn the efficacy of those treatments.121 When its easy to take your pills,youll take them more regularly and they will work better.However,many wearable devices are still in their infancy,and it will take some time before they become readily available.The good news is that brilliant scientists like Dr.Wedyan Babatain are making strides in making wearable technology both effective and affordable.122 Sometimes medicine is more easily prescribed than taken.Patients in developed nations take their meds properly only about half the time,and roughly one-quarter of all patients in these countries simply forget to take their medications or take them the wrong way.123 This lack of adherence causes more than just a waste of good medicine,as well.Failure to take medications exactly as prescribed compromises the efficacy of drugs that require careful maintenance of consistent levels in the patients body and can double the rates of hospitalization for people suffering diabetes,high cholesterol,high blood pressure,or other heart conditions.124 Poor compliance increases resistance to medication as well.A study conducted at the Johns Hopkins Outpatient Center discovered that even a single missed dose materially increased the likelihood of a patient developing a resistance to antiretroviral drugs used to treat HIV.125 With the global rise in anti-microbial resistance,the possibility of individual patients building additional resistances poses a substantial risk,especially in less-wealthy countries.126 Innovate4Health 30 Adherence failure even skews the results of research into that medications effects on a patient demographic,adversely affecting the use of that medication to treat future patients.127 The biggest reason for adherence failure is when the treatment is simply too complex for patients.128 Even taking a single pill once each day can raise difficulties when one considers when in the day that medicine needs to be taken,whether it must be taken with food or on an empty stomach,and whether the medication has dangerous interactions with a patients other prescriptions.Many patients with chronic conditions also stop taking their medications when they feel better,not realizing that they feel better only because they are taking their medications.129 Especially when a medication regimen was a difficult habit in the first place,it may be unduly tempting to give up when a patient feels perfectly healthy.We can improve medication adherence by clarifying patient-provider communications,of course,but it is also important to make those medication regimens easier on the patient.Wearable devices present a compelling option by automating some of the medication procedures.130 These devices can provide diagnostic information to both patient and provider in real time and even serve as a drug delivery apparatus itself.131 Ease of use can nevertheless pose an obstacle for wearable devices too.Many of these devices are rigid,bulky objects that are not only conspicuously ugly but even uncomfortable to use for extended periods.Dr.Wedyan Babatain therefore focused her doctoral research at the King Abdullah University of Science and Technology(KAUST)into developing wearable medical devices built from flexible graphene that can more easily conform to the dynamic surface of human skin.132 Dr.Babatains device includes a system of sensors,processors,and reservoirs that can automate the detection,diagnosis,and administration of medicines.133 Though the device has seen only preliminary testing thus far,it presents immense potential for improving ease of use with difficult medications.Even medications such as insulin that are to be administered as needed will benefit from a device that can constantly monitor the users blood sugar levels and automatically dispense insulin when appropriate.The device is even manufactured using accessible techniques,including 3D printing and screen printing,making it reproducible by facilities with limited availability to more sophisticated technologies.134 Dr.Babatain states that this manufacturing process is viable in“low-resource settings and environments,”allowing broad use of the technology in areas that are most desperate for medical equipment.135 Accessibility as a design theme is consistent even in how Dr.Babatain has documented the development of her device.She has multiple patents associated with her device on file with the World Intellectual Property Organization(WIPO)under the PCT,making the documentation available worldwide.136 Patent law includes disclosure and enablement requirements,meaning that any patent issued on an invention involves publication of documents demonstrating how to reproduce that invention.137 This means that the patent is available to the public even while the invention is still protected by its patent,ensuring that the innovation is shared with the world.Enablement is an essential piece of how patent law enables innovation.As we have discussed in previous Innovate4Health articles,138 one of the most common paths for a new invention to reach widespread adoption 31 is through technology transfer,which relies largely on the enablement elements of patent documentation to facilitate the production of new healthcare innovations like Dr.Babatains wearable devices.139 Through technology transfer,a new inventionmostly commonly created by university researchersgets a patent that then enables a handoff to parties who can refine the invention into a marketable product.Most university labs are ill-equipped for the kind of iterative testing required to make a product fit for general consumption,much less for mass production,so tech transfer programs connect these researchers with firms that specialize in that kind of refinement and production.Consider Smartbone,for example,a Colombian startup which created printable jawbone implants.140 With the help of a patent licensing agreement,Smartbone formed a partnership with distributor Innmetec to make these implants available on a national scale.Brazil saw a similar benefit from tech transfer in the development of Calixcoca,a vaccine against the effects of cocaine.141 Researchers at the Federal University of Minas Gerais(UFMG)developed the vaccine and,with the protections of Brazils analogue to the U.S.Bayh-Dole Act,were able to form a public-private partnership to continue research and development.142 Dr.Babatain and KAUST present a similar story.KAUST offers a robust tech transfer program to its researchers,not only to help them protect their work but also to enable them to share that work with the world.143 The universitys mission explicitly includes the“benefit of the region”in addition to supporting its innovators.Enablement and tech transfer are not limited to commercialization,either.Even in cases where an inventor is more concerned about public wellbeing than their own individual profit,patent protections allow a degree of control over the use of the invention that can make sure it is used to improve the lives of others.Inventors can leverage their patent rights to license their invention primarily to non-profit organizations,for example,and then make separate commercial licensing agreements with corporations that can subsidize the more charitable-distribution of the invention.With the help of KAUST and its technology commercialization office,Dr.Babatain will be able to ensure that her wearable device innovations are made available to the people who most need them.Even if Dr.Babatain is interested only in providing her research to improve upon existing wearable technology,her patent protections and associated enablement will ensure that her brilliant work is responsibly shared with the world.Innovate4Health 32 HydroZitLa Uses Native Flora to Help Fight Kidney Stones By Douglas Park Kidney stones have been described as one of the most excruciatingly painful experiences,sometimes considered even worse than childbirth or severe burns.144 Because the condition is so widespread,treatments are needed all over the world,especially in hot climates like Southeast Asia,where kidney stones are particularly prevalent.Thai university professors have devised a drinkable dietary supplement with both curative and preventive properties to help combat kidney stones.145 Kidney stones,also known as renal calculi,result when minerals crystallize in a patients urinary tract,typically in the kidneys.146 Once they reach a large-enough size,these lumps can cause blood in the urine,urinary difficulty,and excruciating abdominal pain.147 Patients are sometimes asymptomatic until their kidney stones cause infections,which can become life-threatening if not quickly treated.Risk factors for kidney stones vary widely,but the largest factor in their formation is inadequate water intake.148 Without proper hydration,the urinary tract accumulates minerals more quickly than they can be eliminated via urination.This is especially dangerous in hotter climates,where sweat drains the bodys moisture even more quickly.As a result,southern Asian nations are known as a“stone belt”subject to substantially higher incidence of kidney stones.149 For example,ultrasound diagnosis identifies the presence of kidney stones(also known as“nephrolithiasis”or“urolithiasis”)in 16.9 percent of northeastern Thailands population at some point in their lives,with preliminary reports indicating an additional 12 percent prevalence of undiagnosed stones in rural areas.150 By contrast,Germany sees kidney stone prevalence around 4-4.7 percent,while the highest rate is 20 percent in the dry climate of Saudi Arabia.151 These rates are also increasing worldwide.152 Especially in the“stone belt,”growing likelihood of kidney stones presents a threat to many populations,and many patients cannot readily afford expensive treatments like extracorporeal shockwave lithotripsy treatment,a noninvasive treatment that effectively vibrates stones apart.153 Other treatments,such as the urethral insertion of a laser device to break up stones,can be even more expensive,running up to$10,000.154 Given that kidney stones can both result from and increase the likelihood of conditions like kidney disease,diabetes,and cardiovascular disease,the dangers of kidney stones are complicated.155 The issue is further exacerbated by recent research that indicates a correlation between susceptibility to kidney stones and greater oxidative stress.156 33 In essence,oxidative stress refers to the chemical reactions that result from prolonged exposure to oxygen.157 The process of oxidation has been found to increase the likelihood of cancer,cardiovascular disease,various forms of arthritis,and more.In short,oxidation is a major cause of aging.158 All of this brings Dr.Chanchai Boonla and his fellow Chulalongkorn University faculty to their creation of HydroZitLa,a patented liquid dietary supplement that helps prevent buildup of kidney stones.159 HydroZitLa is a blend of citrates and antioxidants harvested from native Thai flora like the blue pea flower and banana stems.It is dispensed in pouches as a concentrate that can be simply mixed into drinking water and served as a beverage.In preliminary trials,research has indicated that HydroZitLa materially reduced mineral deposits in the kidneys of rats without imposing any substantial negative side effects.In fact,HydroZitLa appeared to be as effective in breaking down and preventing kidney stones as Uralyt-U,a drug commonly used to treat stones.160 HydroZitLa was approved by the Thai Food and Drug Administration in 2019,and the supplement can be purchased from vending machines in various locations around Chulalongkorn University.161 This availability would not be possible without Dr.Boonla and his colleagues having patent protections on the concoction.162 Past Innovate4Health articles have described the value of patents in technology transfer programs,and HydroZitLa presents another example of how commercialization and widespread access are made possible by intellectual property.163 Even more importantly,the clinical trials needed to determine the efficacy of HydroZitLa are possible only with substantial funding.Even the in vitro and in vivo testing already done cost money,and human trials are even more expensive.164 Investment in those trials comes only with the security provided by patent law.Clinical trials are not merely a procedural hurdle,either,but a necessary step in refining the safety and efficacy of medicine.Another previous Innovate4Health article has examined the value of traditional medicine in modern healthcare,and HydroZitLa represents a similar opportunity.165 Blue pea flower and banana stem have been used in Thai traditional medicine for some time but combining them with citrate has proven to be an invaluable blend of traditional and modern medicine in the treatment of kidney stones.While traditional medicine itself is not patentable,the improvements made to it through modern science are exactly the innovations that intellectual property seeks to promote.With the proper protections and collaboration between public and private entities made possible by tech transfer and patent rights,kidney stones can be treated as easily as drinking a tasty beverage.Innovate4Health 34 Chapter 4:Challenge:Increasing Efficacy and Removing the Detrimental Side Effects of Existing Therapies Bio is Tech:Re-Imagine Disease Detection Through Konikus Innovative Odor Surveillance System By Natalie Khoo Advancements in silicon and computer technology over the past decade have been nothing short of astounding.From shrinking the computer chip,developing semiconductors,to producing everyday consumer goods,these innovations have driven tremendous progress in various fields including life sciences and medicine.Yet at the heart of humanitys greatest scientific feats lies a more powerful,advanced system that can easily outclass and outmatch any super processorthe neuron.With over 86 billion of these microscopic units interconnected in every human brain,we witness a biological computer with an unparalleled ability to process information.166 Where silicon computers divide tasks among various interacting unitslogic,arithmetic,and memoryeach neuron integrates these functions seamlessly.167 The natural efficiency and compactness of the neuron inspired Oshiorenoya Agabi,a Nigerian neuroscientist,to think beyond traditional silicon-based chips.He envisioned creating a new kind of chip that integrated live neurons themselves,harnessing the inherent capabilities of actual neurons rather than merely emulating them.Together with a team of scientists that includes bioengineers and molecular biologists,Agabi established Koniku,a synthetic biotechnology company.168 Konikus flagship product,the Koniku Kore,is the worlds first neurotechnology device.169 It is a wetware chip that fuses live neurons from mice stem cells with silicon,creating a smell cyborg capable of tasks beyond the reach of conventional technology.170 This smell cyborg,which is 35 smaller than an iPhone and weighs less than 600 grams,consists of a neuron-silicon processing core,sensors that recognize smells,and an electrode that reads and writes information inside the neurons.171 Specifically,the core houses 128 active neurons,more than 50,000 hidden neurons,and 640 electrodes.172 Similarly,this innovative device has the potential to transform how we approach disease detection and health monitoring.By combining live neurons with silicon into a chip,the Koniku Kore can autonomously and intelligently read the air and detect various volatile organic compounds,mimicking the function of a dogs nose.173 This is achieved by engineering proteins in biological neurons to create precise protein particle interactions that can function as sensors,amplifiers,and biological signal processors for various health conditions and environmental hazards,including the detection of cancer and drugs like amphetamines and fentanyl.174 Additionally,the smell cyborg is equipped with a comprehensive data processing and analysis system.The biological-silicon hybrid sensors collect real-time data on airborne compounds and transmit it to cloud services via IoT capabilities.175 This continuous stream of information then feeds into Konikus growing database,which forms the foundation of its machine learning backend.As the system processes and analyzes the data,it becomes increasingly adept at classifying and extracting valuable insights from the vast array of odors that impact human life.As a result,this end-to-end approach enables Koniku to offer a wide range of services,from generating detailed reports to supporting advanced analytics,potentially revolutionizing fields such as early disease detection,environmental monitoring,and personalized health management.176 Konikus innovative neuron-based chip has not gone unnoticed.The company has garnered significant interest from major corporations like AstraZeneca,Boeing,and Cisco,securing substantial investment and partnerships.Since its launch,Agabi and his team have raised$1 million in funding from investors such as Presight Capital,IDO Investments,SoftBank,and HealthCap Africa,to name a few.177 According to Agabi,Koniku has generated$10 million in profits through deals with the aviation and pharmaceutical sectors.It is projected that the market for Koniku Kore could reach up to$145 billion in the upcoming years.Moreover,the success of Koniku goes beyond its financial achievements and market impact.The company has positioned itself as a leader in the neurotechnology field.Building on its success with the proprietary wetware technology stack,the team created the Koniku Technology Integrator System,a community platform designed to facilitate the development and deployment of solutions for businesses ranging from startups to Fortune 500 companies.Koniku has partnered with Airbus to develop solutions for aircraft and airport security,leveraging Koniku Kores ability to detect specific chemicals associated with security threats and Airbuss engineering capabilities across the United States.This collaboration marks a pivotal milestone in Konikus joint go-to-market strategy.Koniku has demonstrated its commitment to innovation through an extensive portfolio of patent filings.Currently,the company holds a patent to protect an electrode that provides superior signal-to-noise ratio recordings from neurons(Patent number:JP6858769)thereby enhancing the quality and accuracy of the recordings compared to traditional two-dimensional or planar electrodes.In addition to this key patent,Koniku has filed numerous other patents covering different aspects of its technology,including the integration of live neurons with silicon,methods for engineering proteins in biological neurons,and advanced data processing Innovate4Health 36 techniques(Patent numbers:WO2024026229A1,WO2022250988A1,US20220263510A1).178 By securing strong intellectual property protection,Koniku ensures that it can continue to innovate and commercialize its technology while protecting itself from imitation by competitors.As we enter a new age of biotechnological innovation,Koniku leads the charge in redefining what is possible.The companys journey illustrates that the most profound advancements often come from looking inward,to the very building blocks of life itself.Their maxim,Bio is Tech,embodies their belief that any sufficiently advanced technology is indistinguishable from nature.37 Calixcoca:A Shot at Sobriety Brazils Innovative Vaccine Aims to Revolutionize Addiction Medicine By Tatyana Norman-Webler Cocaine use disorder(CUD)is a significant public health problem with limited treatment options.While studies are underway,there is no FDA-approved pharmacologic therapy.179 The primary treatment is behavioral therapy.180 But what if people battling CUD didnt experience cravings at all?What if we could vaccinate against cocaine addiction,or any addiction,the way we vaccinate against measles or the flu?With the visionary leadership of Frederico Garcia,a team of researchers at the Federal University of Minas Gerais in Brazil have created a novel anti-cocaine vaccine called Calixcoca.181 After completing his doctoral studies in France in 2011,Dr.Frederico Garcia returned to his hometown of Belo Horizonte,Brazil,and witnessed firsthand the devastation of the crack cocaine epidemic.182 As a professor of psychiatry at the Federal University of Minas Gerais(UFMG),Garcia witnessed the devastating consequences of addiction in his community as local prosecutors penalized mothers suffering from cocaine use disorder by taking their babies at birth.Garcia explained that this is not the time to separate a mother from her newborn baby because this moment is pivotal in the childs development and often in the mothers sobriety.While Brazil does not produce cocaine,the country acts as a bridge for cocaine to travel from Peru,Colombia,and Bolivia to the United States and Europe.183 Brazil is one of the worlds largest consumers of cocaine,second only to the United States.184 Cocaine trafficking and addiction are so challenging and common that a district in Sao Paulo has been dubbed“Cracolndia”or“Crackland.”185 The large number of Americans who also have substance abuse issues further illustrates the global seriousness of the problem.A 2022 survey found that 48.7 million Americans battled substance use disorder(SUD),and of those,27.2 million battled drug use disorder(DUD).186 5.3 million people reported using cocaine in 2022,with the highest use among“young adults aged 18 to 25.”187 A Kaiser Family Foundation poll found that two-thirds of Americans have been impacted by addiction,with 27 percent reporting that a family member had struggled with addiction to an illegal drug.188 While the obvious solution is abstinence,people battling cocaine use disorder are at a high risk of relapse due to the drugs powerful effects on the brain and cravings that are exceptionally difficult to fight.189 Innovate4Health 38 The goal of research into Calixcoca is to stimulate the production of antibodies that latch onto cocaine molecules and prevent them from crossing the blood-brain barrier,making them unable to reach the dopamine receptors that cause a feeling of euphoria.Basically,users would no longer get“high”from cocaine.190 The tricky part is that cocaine by itself is not immunogenicthe molecules are too small for the immune system to recognize.Most vaccines would address this by attaching the cocaine molecules to larger proteins that the immune system can process,but that requires a prohibitively complex process of sterilization and refrigeration.191 Instead,the Calixcoca team used large carrier molecules called calixarenes.192 They attached molecules that imitate the structure of cocaine molecules to these calixarene carriers to train the immune system to combat anything that looks like cocaine.A 2021 study in mice demonstrated immunological potential and the ability of both calixarene carriers to bind to cocaine-like molecules to prevent them from reaching the brain.193 They have since successfully demonstrated the safety and effectiveness of the final product,UFMG-VAC-V4N2,i.e.,Calixcoca,in monkeys.194 With$10 million in government funding,the team hopes to begin human trials later this year.The team plans to start with a group of 30 individuals in Phase I clinical trials and progress to 300 individuals in Phase II clinical trials.UFMG partnered with hospitals and clinics to recruit patients with CUD who have abstained from cocaine use because of their admission.Clinical trial participants would receive a total of three intramuscular doses of Calixcoca.Clinical trials will monitor abstinence not only through regular urine screens,but also by sociological and psychological metrics.How soon were participants able to obtain a job?Have they reconnected with family?Garcia hopes that anti-cocaine vaccines will not only treat individuals battling CUD but also serve as a preventative treatment for fertile women who battle CUD.He explained that only one-quarter of pregnant women with CUD manage to stop using while pregnant.Intellectual property has been integral to Calixcocas development.With the help of UFMGs technology transfer office,Garcias team secured a patent to protect their novel anti-cocaine molecules from the Brazilian Patent Office in 2017(BR 10 2017 015955 8),and their patent was granted in the United States.195 Garcia hopes that patent protection and successful Phase I trials will help raise more funding from private firms.Calixcoca recently won the Euro Health Innovation Award in October 2023,securing the top prize of 500,000 euros.196 The Brazilian government sees the potential in this research.Garcia shared that the government recently invested$1 billion in building a state-of-the-art biopharmaceutical research center.In 2004,Brazil enacted the Innovation Law(Law No.10973/04),modeled after the U.S.Bayh-Dole Act,which incentivizes innovation and public-private collaboration by affording patent protection to publicly funded research at universities.197 The law was last amended in 2018 to create mechanisms that bring“more legal security to the parties around the technologies that are jointly developed.”198 Sao Paulo is already known as the“largest innovation ecosystem in Latin America,”and with the help of federal investment,robust patent protections,and UFMGs technology transfer program,Garcia hopes that Brazil will become the worlds leading biopharmaceutical pipeline.199 39 Garcia noted that the drug that revolutionized cardiovascular treatmentCaptopril and the derivative family of ACE-Inhibitors that followedwas invented in Brazil using venom from a poisonous Brazilian viper.200 Now,Frederico Garcia and the Calixcoca research team hope to transform millions of lives by revolutionizing addiction medicine and transforming Belo Horizonte into a biopharmaceutical innovation hub.Innovate4Health 40 Innovative Cure For All:How CurASeals Plant-Based Technology Advances Bleeding Control and Wound Healing By Natalie Khoo Wound care and hemorrhage management are essential aspects of medical treatment,particularly in surgical procedures.Traditionally,these practices have relied on a combination of dressings,antibacterial agents,and antiseptics to prevent infection,promote healing,and control bleeding.201 However,the growing prevalence of antibiotic-resistant bacterial strains and the potential for antiseptics to damage healthy tissue have increasingly called the effectiveness of these conventional methods into question.As a result,there has been a growing shift toward more advanced antimicrobial wound care solutions which are often enhanced with bioactive compounds.The demand for such advanced solutions has become even more apparent in recent years due to disruptions in global supply chains,particularly during the COVID-19 pandemic.Countries in the Middle East and North Africa(MENA)region such as Egypt and Saudi Arabia,which have long depended on imported medical supplies,encountered significant challenges in obtaining these life-saving products.With approximately 90 percent of medical supplies coming from outside the region,namely the United States and Germany,the MENA medical device import market was valued at over$13.1 billion in 2022.202 These challenging times have underscored the critical need for local production of medical devices,which is essential not only for ensuring supply chain resilience but also for reducing costs and increasing accessibility to essential healthcare products.203 Rooted in the principles of“innovating medical devices for today,tomorrow and whats needed next,InCurA,an Egypt and Saudi-based IP deep-tech company,is setting out to democratize access to high-quality medical devices in the MENA region.204 Founded by Mousa Salem and Wesam Sarhan,InCurA focuses on developing a pipeline of cost-effective hemostatic products that not only meet but exceed global standards.205 Leveraging its unique know-how and cutting-edge technologies,InCurA utilizes the latest advancements in machine learning to develop a novel line of AI-optimized devices which have now been licensed for production in Saudi Arabia with major industry players such as ROYAH Pharmaceuticals and Cighala Healthcare.206 Among InCurAs groundbreaking products is CurASeal,a 100 percent plant-based starch hemostatic powder designed to control bleeding effectively and rapidly.207 Unlike conventional hemostatic agents,CurASeal employs a patent application Nano-in-Microsphere technology,complemented by perforated microparticles that enable rapid blood clotting in seconds.208 This innovative structure ensures complete absorption by the body within 48 hours.Similarly,the starch-porous microparticles feature a unique concave,red-blood-cell-like structure and nanopores on the surface,allowing for instant and complete blood penetration,setting it apart 41 from existing products like Arista(BDs hemostatic powder)and SURGICEL Powder(J&J).which only offer partial or no penetration.Besides,CurASeals versatility makes it suitable for a wide range of surgical applications,including vascular,urology,cardiothoracic,orthopedic,general,and plastic surgeries.Available in 1gm and 3gm sizes,CurASeal is engineered to perform optimally in narrow and hard-to-reach surgical sites,providing the quickest blood clotting activity.209 This is achieved through three synergistic mechanisms:concentrating cellular and protein components for clot formation,amplifying thrombin formation to accelerate the coagulation cascade,and exhibiting antifibrinolytic activity to maintain a stable clot.210 InCurAs success can be attributed to its robust IP portfolio,which covers various facets of its composition and manufacturing process.For instance,the products starch microparticles are specifically designed for enhanced blood penetration and adhesion,which significantly improves its efficacy compared to other products on the market.Additionally,by eliminating enzymes from the formulation,InCurA has managed to reduce production costs,allowing CurASeal to be competitively priced and accessible to markets with critical needs,such as those in Africa.This strategic intellectual property management has not only safeguarded the companys innovations but also ensured its ability to meet urgent healthcare needs efficiently.This success is further bolstered by the companys strategic initiatives and recognition in the industry,which have garnered significant recognition and investment.InCurA has secured funding from prominent investors,including Kaust Innovation Ventures,to support its mission of democratizing access to high-qu
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itif.org How Innovative Is China in Biotechnology?SANDRA BARBOSU|AUGUST 2024 China used to be considered a laggard in biotech.But with a comprehensive national strategy and extensive resources now supporting the industry,it is becoming more innovative.In fact,several indicators suggest it is narrowing the innovation gap with global leaders in the West.KEY TAKEAWAYS Recent Chinese government policies have emphasized domestic biotech innovation.A new national strategy has been crucial to the sectors growth.Several factors are spurring growth,including subsidies,financial incentives,science parks,start-up incubators,talent recruitment schemes,public-private partnerships,and reforms to expedite drug review and enhance IP protection.Indicators suggest Chinese biotech is becoming more innovative.For example,the U.S.FDA approved three new Chinese drugs in 2023.Chinas out-licensing deals grew from 15 in 2019 to 33 in 2023,with the largest increase being in oncology.These deals consisted of a range of therapeutic modalities,involving both small molecule and biologics.Clinical trial activity in China more than doubled from 2,979 trials in 2017 to 6,497 trials in 2021.In oncology,Chinese trials grew 146 percent from 1,040 in 2017 to 2,564 in 2021,the highest for any country.China still lags behind in its ability to turn science into products.America remains ahead,leveraging its sophisticated ecosystem of national funding sources,VC start-up funding,pharma R&D investment,robust IP,and strong commercialization ability.China increased its global share of value-added pharmaceuticals output from roughly 5.6 percent in 2002 to 24.2 percent in 2019.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 2 CONTENTS Key Takeaways.1 Executive Summary.3 Background and Methodology.4 Importance of Biotechnology and the U.S.Role.4 Chinas Biotechnology Industry.5 How Innovative Is Chinas Biotech Industry?.6 New Drugs.7 Out-Licensing Deals.8 Clinical Trials.10 Innovation Inputs to Chinas Biotech Sector.13 Scientific Publications.13 Biological Manufacturing.15 Genome and Genetic Sequencing and Analysis.16 Genetic Engineering.18 Novel Antibiotics and Antivirals.19 Patents.20 Venture Capital.22 Company Case Studies.23 BeiGene.23 Hengrui Pharmaceuticals.25 Chinas Government Policies Supporting the Biotech Sector.26 Early Building Blocks.26 National Biotechnology Strategy.27 High-Tech Parks.28 Regulatory Environment.29 IP Protection.30 IP Theft.30 Scientific Talent.31 Price Controls.32 What Should America Do?.33 Conclusion.35 Endnotes.36 INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 3 EXECUTIVE SUMMARY Austrian-Czech scientist Gregor Mendel laid the mathematical foundation of the science of genetics when he identified genes as the fundamental unit of inheritance in 1865.1 Nearly 90 years later,in 1953,the work of scientists James D.Watson,Francis H.C.Crick,Maurice Wilkins,and Rosalind Franklin led to the discovery of the structure of DNA,the molecule containing human genes.2 Their discovery marked the beginning of modern biotechnology,which has a wide range of applications,including in human health,the primary focus of this report.The biotechnology industry uses living organisms and biological processes to develop drugs,drawing on areas including molecular biology,synthetic biology,genetic engineering,bioinformatics,and-omics technologies,among others,for drug discovery and development.Biotech is one branch of the broader biopharmaceutical sector,which encompasses biotech and pharmaceutical companies.Both produce medicines,but from different sources and through different modalities.While biotech focuses on the development of biologics,which are large,complex molecules derived from living organisms,such as monoclonal antibodies,vaccines,and gene therapies,pharma focuses on medicines with a chemical basis,synthesized from chemical compounds,such as small molecule drugs.3 The United States remains the worlds biotechnology leader with the highest level of new drug development.A sophisticated U.S.ecosystem,composed of national research funding sources,venture capital and private equity(VC/PE)start-up funding,large pharmaceutical firms that support life-sciences research and development(R&D),robust intellectual property(IP)protections,and strong commercialization ability have produced a globally unique environment that powerfully supports domestic biotechnology innovation.But this leadership position is at risk without a continually supportive domestic policy environment amidst robust foreign competition,particularly from China.Until recently,Chinas playbook was to imitate the advances of industrialized countries,but since the 12th Five-Year Plan(20112015),the Chinese government has shifted its strategy toward incentivizing innovation,naming biotech as a strategic emerging industry and providing substantial support.4 In 2016,China committed itself to improving health outcomes for the Chinese population through its“Healthy China 2030”strategy,which focuses on medical innovation and improving access to drugs.5 More specifically,China has developed a comprehensive national strategy to enhance the innovation capabilities of its domestic biotech industry.The strategy includes subsidies;financial incentives;the initiation of national reimbursement for innovative therapies;the establishment of high-tech science parks,start-up incubators,and public-private partnerships;talent recruitment initiatives;reforms to expedite drug review,especially for domestic products;and efforts to enhance IP protection to foster innovation.China has set several milestones and goals for the industry,such as enhancing the originality of biotech through new technologies and products,creating a biotech innovation platform,and strengthening the industrialization of biotech.Several recent indicators suggest that Chinas domestic biotech industry is indeed becoming more innovative.These include an uptick in the volume and quality of biotech-related scientific publications,a growing number of novel Chinese drugs approved by the U.S.Food and Drug Administration(FDA)and Chinas National Medical Products Administration(NMPA),an increase in out-licensing deals from small Chinese biotech companies,particularly in oncology,and a rise in clinical trials occurring in China.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 4 Despite recent progress,China still faces challenges in commercializing scientific discoveries into market-ready products,such as novel therapeutics.Doing so requires a different skill set from producing scientific innovations.The United States continues to lead in this area,leveraging its sophisticated ecosystem comprising national funding sources,VC start-up funding,pharmaceutical R&D investment,robust IP protections,and strong commercialization abilities.For China to realize its ambition of becoming a global biotech superpower,it will be important for it to develop a comprehensive biotech ecosystem and enhance its commercialization capabilities through approaches such as technology transfer from research to industry.BACKGROUND AND METHODOLOGY The common narrative is that China is a copier and the United States is the innovator.That narrative often supports a lackadaisical attitude toward technology and industrial policy.After all,the United States leads in innovation,so there is little to worry about,with the exception of perhaps making sure the country deepens its science,technology,engineering,and mathematics(STEM)skill base.First,this assumption is misguided because innovators can lose leadership to copiers with lower cost structures,as we have seen in many U.S.industries,including consumer electronics,semiconductors,solar panels,telecom equipment,and machine tools.6 As Clayton Christensen has shown,followers often attack at the lower end of the market through copying and significant cost advantages and work their way up toward higher value-added and more-innovative segments.7 Second,it is not clear that China is a sluggish copier and always destined to be a follower.To assess how innovative Chinese industries are,the Smith Richardson Foundation provided support to the Information Technology and Innovation Foundation(ITIF)to research the question.As part of this research,ITIF is focusing on particular sectors,including the biotechnology industry.To be sure,it is difficult to assess the innovation capabilities of any countrys industries,but it is especially difficult for Chinese industries.In part,this is because,under President Xi Jinping,China discloses much less information to the world than it used to,especially about its industrial and technological capabilities.Notwithstanding this,ITIF relied on three methods to assess Chinese innovation in biotechnology.First,we conducted an in-depth case study evaluation of two biotechnology companies that originated in China listed on the“2023 EU Industrial R&D Investment Scoreboard.”Second,ITIF conducted interviews and held a focus group roundtable with global experts on the Chinese biotechnology industry,allowing participants to speak anonymously,unless they expressed they wished to be named in the report.8 And third,we assessed global data on biotechnology innovation,including scientific articles,patents,and novel drug applications.IMPORTANCE OF BIOTECHNOLOGY AND THE U.S.ROLE The biotechnology industry uses materials derived from living organisms to produce innovations that help improve human lives.The sectors numerous applications range from the development of therapeutics and diagnostics to improve human health to energy production,waste treatment,and genetically modified crops for agriculture,among others.9 This report focuses primarily on the healthcare applications of biotechnology.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 5 Biotechnology can help advance human health in different ways.It can support precision medicine by tailoring therapeutics to individual patients,making them more effective and reducing side effects.Methods such as genetic sequencing and molecular diagnostics help identify specific genetic mutations associated with disease to determine the most suitable therapies based on individuals unique genetic profiles.10 The biotech industry also enables the production of biologics,drugs derived from living organisms or their components,such as therapeutic proteins,monoclonal antibodies,and vaccines.Biologics provide targeted treatments for serious diseases such as cancer and autoimmune disorders,inflammation-related conditions,hemophilia,and diabetes,among others.11 Biotech also has applications in gene therapies.Gene editing technologies such as CRISPR-Cas9 enable scientists to modify cells DNA,which could help treat genetic disorders by correcting disease-causing gene mutations.These examples illustrate the range of applications of biotech in healthcare,and the ways in which its outputs are critical to improving human lives.12 The United States remains the global leader in biotech,with the highest level of new drug development in the world.From 2014 to 2018,U.S.-headquartered enterprises produced almost twice as many new chemical or biological entities(NCEs and NBEs)as European ones,and nearly four times as many as Japan.13 But this leadership position is at risk without a more supportive domestic policy environment amidst robust foreign competition,particularly from China.The United States owes its biotechnology leadership to several factors,including strong research universities and institutions such as the National Institutes of Health(NIH)and the Advanced Research Projects Agency for Health(ARPA-H)that fund basic research;supportive science policies such as the Orphan Drug Act of 1983 and the Prescription Drug User Fee Act(PDUFA)of 1992 that aim to incentivize innovation;a robust IP protection regime,including strong patent rights and enforcement that encourage innovation;and the existence of supportive innovation clusters of collocated universities,companies,and incubators.These clusters facilitate knowledge and resource sharing,playing a critical role in transforming scientific ideas from the laboratory into commercial products such as novel therapeutics.According to a McKinsey Biocentury report,China has seen the recent emergence of four leading biotechnology clusters:the Bohai Rim Cluster,located in Beijing,Tianjin,and Jianin;the Yangtze River Cluster,located in Shanghai,Suzhou,and Hangzhou;the Mid-West Cluster,in Wuhan and Chengdu;and the South China Cluster,located in Shenzhen,Guangzhou,and Xiamen.Over 8,500 biotech and biopharma companies are found in these leading biohubs.14 CHINAS BIOTECHNOLOGY INDUSTRY Traditional forms of biotechnology have existed in China since its earliest days.During the Sui Dynasty in the 6th and 7th centuries,a smallpox vaccine was developed,which became widely available in China by the Ming Dynasty,in the 14th century.15 More recently,the 1980s was a period of growth for Chinas modern biotech industry.In 1987,China launched the 863 Program,providing support to 15 science and technology sectors,one being biotech,to stimulate the development of advanced technologies,particularly in genetic engineering,vaccination,and gene therapy.16 This was both to prepare for public health crises and to respond to international INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 6 competition,as other countries had established their own science and technology strategies.China has seen significant growth in its life sciences industries since the start of the current century.According to data from the National Science Foundation(NSF),value added output of Chinas pharmaceuticals industry increased its global share from roughly 5.6 percent in 2002 to 24.2 percent in 2019.At the same time,the global share for the United States and the European Union have steadily declined.(See figure 1.)Figure 1:Global shares of value added in pharmaceuticals17 Until recent years,Chinas playbook was to imitate the advances of industrialized countries,but since the 12th Five-Year Plan(20112015),the Chinese government has shifted its strategy toward incentivizing innovation,naming biotech as a strategic emerging industry,and setting development priorities for drugs,biomedical engineering,agriculture,and biomanufacturing.18 According to the National Science Foundation(NSF),value added output of Chinas pharmaceuticals industry increased its global share from roughly 5.6 percent in 2002 to 24.2 percent in 2019.HOW INNOVATIVE IS CHINAS BIOTECH INDUSTRY?Several indicators suggest that Chinese biotech is indeed has become more innovative in recent years,following its governments strategic shift to support innovation in the sector.These indicators include a growing number of novel Chinese drugs,a rise in R&D companies,an increase in out-licensing deals from small Chinese biotech companies,particularly in oncology,and a surge in clinical trials taking place in China.0%5 %05 0220042006200820102012201420162018United StatesChinaEUINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 7 Chinese biotech companies are increasingly establishing global footprints.Out of the top 10 Chinese biotechnology companies,9 have established overseas operations in more than 15 countries,including overseas R&D centers,offices,and manufacturing sites.19 The building blocks of biomedical innovation have been changing to facilitate research into complex conditions such as cancer and the development of new types of drugs.Notably,genetic databases are becoming the holy grail of drug discovery and development,and the Chinese government has supported the creation of gene and cell banks.Yet,Scott M.Moore,practice professor of political science,University of Pennsylvania,explains that while Chinas large databases can help spur innovation in areas such as cancer therapeutics and CAR-T cell therapy,there are also logistical issues,including inconsistent hospital recordkeeping,and challenges surrounding how data is structured and coded,that China still needs to overcome.20 Chinese biotech companies are increasingly establishing global footprints.New Drugs A 2023 study finds that the number of Chinese domestic medicine approvals increased between 2011 and 2021.21(See figure 2,recreated from the study.)22 Figure 2:Number of NMPA domestic and imported drug approvals in China23 In 2023,China had five first-in-class domestic drug approvals,a sign that domestic innovation is increasing.The five drugs approved were Glumetinib(Haihe Biopharma),Leritrelvir(Raynovent),Anaprazole(Xuanzhu Biopharma),Pegol-Sihematide(Hansoh Pharma),and Zuberitamab(BioRay Biopharmaceutical).24 These drugs treat a range of conditions:mild or moderate COVID-19 symptoms,acid reflux,anemia in chronic kidney disease,and cancer.Also in 2023,the FDA 0102030405060708020112012201320142015201620172018201920202021ImportedDomesticINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 8 approved three new Chinese drugs:Loqtorzi(toripalimab),the first FDA-approved drug for nasopharyngeal cancer,Fruzaqla(fruquintinib)for metastatic colorectal cancer,and Ryzneuta(efbemalenograstim)for the treatment of chemotherapy-associated neutropenia.25 An industry expert highlights that beyond the focus on truly novel,first-in-class drugs,two other kinds of innovation are important in the biotech industry:first,innovation using the resources of brute force,and second,innovation that improves current technologies.Focusing only on first-in-class innovation might obscure the other two,which are also critical for the development of the industry,and can also serve as building blocks for the first type of innovation.In recent years,China has focused on developing novel drug types,including monoclonal and CAR-T cell products,which show promise in cancer immunotherapy.An industry expert explains that Chinese biotech companies are conducting innovative work in cutting-edge modalities and small molecule drugs,and that the number of companies with innovative drug R&D pipelines is on the rise.Citeline finds that the share of companies involved in pharma R&D headquartered in China has increased from 5 percent in 2017 to 16 percent in 2024.26(See figure 3.)Figure 3:Share of global companies involved in biopharmaceutical R&D27 While FDA approval is one valuable measure of new product innovation,George Baeder,a biotech executive with 30 years of experience in China,explains that an equally interesting innovation measure is the number of innovative Chinese drugs licensed by foreign multinational companies(MNCs).28 Out-Licensing Deals According to a November 2023 McKinsey BioCentury report,China evinces increasing numbers of out-licensing deals,suggesting growing confidence of MNCs in the quality of Chinese biotech 0 0P 172018201920202021202220232024United StatesChinaINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 9 products.This number more than doubled from 15 in 2019 to 33 in 2023.(See figure 4,recreated from the report.)29 The largest rise has been in oncology,which experienced a nearly fourfold increase from seven out-licensing deals in 2019 to 27 in 2023,accounting for the greatest share of out-licensing deals.(See figure 5,recreated from the report.)30 Figure 4:Number of Chinese out-licensing deals31 Figure 5:Number of Chinese out-licensing deals by therapeutic area32 0510152025303520192020202120222023(JanNov)0510152025303520192020202120222023(JanNov)OthersImmunologyMetabolicNeurologyAnti-infectionsOncologyINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 10 For example,in May 2023,Roche announced a partnership with Chinese biotech company Zion Pharma,through which it will pay Zion$70 million up front for a new orally delivered breast cancer drug.The drug,which targets the HER2 protein,is currently in Phase 1 clinical trials in the United States and China.33 In January 2021,Novartis announced a collaboration and licensing agreement with BeiGene to develop and commercialize BeiGenes anti-PD-1 antibody tisleziumab in the United States,European Union,and other countries.34 In 2021,Eli Lilly entered a$1.5 billion deal with Chinas Regor Therapeutics for a multi-year research collaboration and licensing agreement to develop new therapies for metabolic disorders,leveraging Regors Computer Accelerated Rational Discovery(CARD)platform.35 And in December 2023,GSK entered into an exclusive license agreement with Chinese company Hansoh Pharma for an antibody-drug conjugate(ADC)targeting solid tumors.36 Beyond drugs,the industry is also making advances in multi-cancer early detection(MCED)tests,which involve the application of genome sequencing techniques to detect common cancer features in the blood.Through the Chinese governments support,MCED developers can access state capital,academic biobanks,and other resources.This gives them an advantage over their American counterparts,which do not have access to the same resources and thus have to rely heavily on private sector investment to obtain them.Important Chinese MCED players include BurningRock Dx,SeekIn,Berry Oncology,Singlera Genomics,and GeneSeeq.In 2023,SeekIn and Dutch OncoInv entered a partnership that enhanced Chinas international collaboration and expanded the global accessibility of MCED tests.37 Scientists in China have also recently created an AI-based test that can detect cancer,including pancreatic,gastric,and colorectal cancer,using a single spot of dried blood.This technique is cheap and easy to perform and transport,making it more accessible to underserved populations and less-developed countries.38 But as the mortality rates from infectious diseases fell,Chinas focus shifted to chronic diseases,such as cardiovascular and metabolic disorders,and eventually,oncology.China seized the opportunity to develop treatments for these diseases at lower cost structures.Baeder says that the Chinese biotech industrys focus on canceras evidenced by its novel drugs,out-licensing deals,and diagnostic tests in this therapeutic areais relatively new.and motivated in large part by Chinas aging population and the rising incidence of cancer.This combination makes China one of the largest and fastest growing countries for new cancer diagnosis and treatment.Previously,its domestic biopharmaceutical industry focused on one health care priority:bringing down infectious disease.This led China to become the global leader in penicillin production,vaccines,and other antibiotics.But as the mortality rates from infectious diseases fell,Chinas focus shifted to chronic diseases,such as cardiovascular and metabolic disorders,and eventually,oncology.China seized the opportunity to develop treatments for these diseases at lower cost structures.39 Clinical Trials By several measures,China has already overtaken the United States as a site for clinical development.According to a 2022 report from GlobalData Healthcare Consulting,clinical trial activity between 2017 and 2021 more than doubled in China,from 2,979 trials in 2017 to INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 11 6,497 trials in 2021,while the United States saw only a 10 percent increase during this time,from 4,557 to 5,008 trials.40 In oncology,the number of clinical trials grew from 1,040 in 2017 to 2,564 in 2021,a 146 percent increase.Meanwhile,in the United States,oncology clinical trials grew from 1,664 in 2017 to 1,690 in 2021,a 1.56 percent increase.(See figure 6 for U.S.clinical trials,and figure 7 for Chinese trials in the top five therapeutic areas.)41 Figure 6:Number of trials in top five therapeutic areas,United States42 The number of clinical oncology trials in China increased 146 percent from 2017 to 2021.Meanwhile,the number of clinical oncology trials in the United States grew 1.56 percent.02004006008001,0001,2001,4001,6001,800OncologyCentral nervoussystemInfectiousdiseasesCardiovascularGastrointestinal20172021INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 12 Figure 7:Number of trials in top five therapeutic areas,China43 Analysis from Vital Transformation,a health care economics consultancy,also shows a surge in Chinese clinical trials for Alzheimers,from just one trial in each of 20202022,to 23 trials in 2023.(See figure 8.)44 Figure 8:Number of Alzheimers disease clinical trials originating from Chinese pharma companies45 05001,0001,5002,0002,5003,000OncologyCentral nervoussystemInfectiousdiseasesCardiovascularGastrointestinal2017202105101520252020202120222023INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 13 Further,a 2024 IQVIA report shows that the share of clinical trials launched by Chinese-headquartered biopharmaceutical companies rose from 3 percent in 2013 to 28 percent in 2023,suggesting a growing involvement of Chinese companies in early-phase drug development.46(See figure 9,drawing on data from the report.)Figure 9:Share of clinical trial starts based on company headquarters location47 Baeder explains that as clinical development becomes more narrowly focused(e.g.,based on biomarkers that target subsets of patients),the availability of patients and the speed at which they can be recruited have a significant impact on both speed to market and economics.While Chinas process for approving trials still lags behind that of the United States,recruitment is much faster due to the comparatively large numbers of treatment patients in many disease areas.Baeder also states that Chinese clinical trial costs are generally 25 to 40 percent less than those in the United States,and taken together,these factors are turning China into a leading site for clinical development.For companies,this creates the opportunity to accelerate and lower the cost of the most expensive and time-consuming component of bringing a drug to market while at the same time helping firms gain access to the worlds largest market for many diseases.INNOVATION INPUTS TO CHINAS BIOTECH SECTOR This section of the report examines indicators assessing Chinas biotechnology competitiveness at the industry level,considering such factors as scientific publications,patenting levels,and venture capital investment.Scientific Publications Chinese institutions are producing an increasing number of top-cited publications.In 2012,they published 139 biotech papers in the top 10 percent of most-cited publications.(See figure 10.)By 2022,that number had surged to 671 top-cited papers,an increase of more than 382 0510152025303540United StatesChinaEurope20132023INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 14 percent.Meanwhile,the number of publications from other countries has been relatively stable or slightly decreasing.In the United States,this number decreased from 218 in 2012 to 145 in 2022,a nearly 34 percent decrease.Figure 10:Number of biotechnology publications in top 10 percent of most-cited publications48 One can see a similar trend in global shares of publications.Between 2012 and 2022,the share of Chinese publications appearing in top-cited publications steadily grew from about 9.3 percent to about 13.4 percent.(See figure 11.)Figure 11:Share of biotechnology publications in top 10 percent of most-cited publications4949 0100200300400500600700800201220142016201820202022ChinaEU 27United States0%2%4%6%8 1220142016201820202022ChinaUnited StatesEU 27INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 15 Biological Manufacturing Data from the Australian Strategic Policy Institute,which tracks biotech in its Technology Tracker,shows that,in 2023,Chinese publications accounted for about 19 percent of all scientific publications in biological manufacturing.Similarly,Chinese publications accounted for 26 percent of all publications in top-cited journals,making China first in the world in terms of overall publications and high-impact publications in this field.(See figure 12).Moreover,China also ranks first in its H-index for biological manufacturing,just ahead of the United States.(See figure 13.)The H-index,an author-level metric that measures both the productivity and citation impact of publications,is another commonly used metric.Figure 12:Global share of scientific publications in biological manufacturing by country,202350 Chinese publications in 2023 accounted for about 19 percent of all scientific publications in biological manufacturing.0%5 %0%ChinaUnited StatesIndiaItalyUnited KingdomSouth KoreaBrazilGermanyIranAustraliaShare of publicationsShare in the top 10%most-citedINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 16 Figure 13:H-Index for scientific publications in biological manufacturing,202351 Genome and Genetic Sequencing and Analysis In 2023,Chinese articles accounted for roughly 33 percent of all scientific publications in the field of genome and genetic sequencing and analysis.Similarly,Chinese publications accounted for 31 percent of all publications in the top-cited journals,making China first in the world in scientific publications in this field.(See figure 14.)China also ranks highly in its H-index for genetic sequencing,second behind the United States.(See figure 15.)010203040506070ChinaUnited StatesIndiaItalyIranUnited KingdomSouth KoreaAustraliaBrazilGermanyINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 17 Figure 14:Global share of scientific publications in genome and genetic sequencing and analysis,20235252 Figure 15:H-Index for scientific publications in genome and genetic sequencing and analysis,20235353 0%5 %05%ChinaUnited StatesUnited KingdomGermanyJapanFranceAustraliaCanadaSpainShare of scientific publicationsShare in the top 10%most-cited050100150200United StatesChinaUnited KingdomGermanyAustraliaFranceCanadaJapanSpainINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 18 Genetic Engineering In 2023,Chinese publications constituted nearly 27 percent of all scientific publications in genetic engineering,second to the United States 28 percent,and roughly 26 percent of all publications in top-cited journals,second to the Unites States 41 percent.(See figure 16.)China also ranks second to the United States in its H-index for genetic engineering(figure 17).Figure 16:Global share of scientific publications in genetic engineering,20235454 Figure 17:H-Index for scientific publications in genetic engineering,20235555 0 0P%United StatesChinaGermanyUnited KingdomSouth KoreaJapanFranceCanadaShare of publicationsShare in the top 10%most-cited050100150200United StatesChinaUnited KingdomGermanySouth KoreaJapanFranceCanadaINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 19 Novel Antibiotics and Antivirals In 2023,Chinese publications held a share of about 21 percent of all scientific publications in novel antibiotics and antivirals.Similarly,Chinese publications had a share of about 28 percent of all publications in top-cited journals,placing the country ahead of the United States on both measures.(See figure 18.)China also ranks highly in its H-index for novel antibiotics and antivirals,ranking first in the world.(See figure 19.)Overall,these findings suggest that China is a leader not only in the quantity,but also in the quality,of scientific publications in fields relevant to the biotech industry.Figure 18:Global share of scientific publications in novel antibiotics and antivirals,20235656 These findings suggest China is a leader not only in the quantity,but also in the quality of scientific publications in fields relevant to the biotech industry.0%5 %0%ChinaUnited StatesIndiaIranEgyptUnited KingdomGermanySouth KoreaItalyCanadaShare of publicationsShare in the top 10%most-citedINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 20 Figure 19:H-Index for scientific publications in novel antibiotics and antivirals,20235757 Patents China has also made significant strides in turning its scientific publications into biotechnology patents.The Patent Cooperation Treaty(PCT),which entered force in 1978,allows innovators to seek protection for an invention simultaneously in each of a large number of countries through an“international”patent application.58 The PCT is not the only way of filing patents internationally;there are also other routes to protect IP across countries,including individual applications to the patent offices of each country,regional applications that cover multiple countries,and the Paris Convention Route,which is far older than PCTs,and is also less expensive,but lacks the coordination mechanism of the PCT.This section uses PCT filings to compare patent activity across countries because the PCT provides a standardized,comprehensive,and accessible dataset that reflects international innovation trends and patent strategies.From 2013 to 2023,the number of biotech PCT patents awarded to Chinese entities increased by more than 720 percent,from 266 to 1,920,exceeding the European Unions annual number starting in 2021.While this represents a 622 percent increase(albeit from a low starting point),the number of patents awarded to U.S.filers over the same period increased by 67 percent.(See figure 20.)When considering the global shares of biotechnology PCT patents,Chinas share increased by 15 percentage points from 4.8 percent in 2013 to 19.8 percent in 2023.(See figure 21.)By contrast,the U.S.global share declined slightly by 1.8 percentage points,while the EU saw a more significant decline of 9.5 percentage points.020406080100120140ChinaUnited StatesIndiaIranUnited KingdomEgyptGermanySouth KoreaItalyCanadaINFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 21 Figure 20:Number of PCT publications in biotechnology59 Figure 21:Global shares of PCT patent publications in biotechnology60 05001,0001,5002,0002,5003,0003,5004,000201320152017201920212023United StatesChinaEU 270%5 %05E 1320152017201920212023United StatesChinaEU 27INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 22 Venture Capital According to NSF,the total biotechnology VC raised by Chinaas determined by the VC financing raised by Chinese-headquartered firmshas surged.Chinas share of global biotechnology VC raised grew from a mere 3.5 percent in 2010 to 18.9 percent in 2020.At the same time,the U.S.share declined from about 68.6 percent to 62.1 percent.Europe(including non-EU countries)saw an even greater decline over that same period from about 24.9 percent to 14.5 percent.(See figure 22.)61 Figure 22:Global shares of biotechnology venture capital raised62 Chinas share of biotechnology VC raised grew from 3.5 percent in 2010 to 18.9 percent in 2020.0 0Pp%United StatesChinaEurope20102020INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 23 COMPANY CASE STUDIES This section provides case study analyses of two biotechnology companies that originated in China.They were intentionally selected from those companies included on the“2023 EU Industrial R&D Investment Scoreboard”report.BeiGene Founded in Beijing in 2010,BeiGene has grown into a global multinational oncology innovation company dedicated to developing both best-in-class and first-in-class clinical candidate drugs.The company operates on five continents and focuses on immuno-oncology,hematological oncology,and solid tumors and has built a diversified technology platform and product pipeline through in-house research and business development.BeiGene is a fully integrated company covering preclinical research,global clinical trial operations,large-scale drug manufacturing,and commercialization.BeiGene employs more than 10,000 individuals worldwide,including over 3,000 global clinical research personnel.The company relies significantly on its in-house R&D team,which reduces its dependence on Contract Research Organizations(CROs).The founders,John V.Oyler,an American entrepreneur,and Xiaodong Wang,a Chinese-American biochemist,were driven by the belief that it was possible to run high-quality clinical trials in China that were global in nature and design,enabling them to enroll patients and run trials more quickly and cheaply,supporting innovation.63 Today,BeiGene boasts a powerful in-house clinical development operation that leverages Chinas faster recruitment and lower cost structure.The company has independently conducted over 130 clinical trials,enrolling more than 22,000 participants across 45 countries and regions.64 BeiGene has also developed robust internal production capabilities.Its biopharmaceutical manufacturing facility and clinical R&D center in Hopewell,New Jersey,is nearing completion,and its newly completed small molecule innovation drug industrialization base in Suzhou,China,will expand solid-dosage-form production capacity to 1 billion tablets(or capsules)per year.Its biopharmaceutical production facility in Guangzhou,China,has reached a total capacity of 65,000 liters,with completed ADC production facilities and a new biopharmaceutical clinical production building.Currently,BeiGene has three internally developed and approved drugs on the market:Brukinsa(zanubrutinib),a small molecule Brutons tyrosine kinase(BTK)inhibitor for treating various hematological malignancies;tislelizumab,an anti-PD-1 antibody immunotherapy for solid tumors and hematological malignancies;and pamiparib,a selective small molecule inhibitor of PARP1 and PARP2.Brukinsa has been approved in over 70 countries and regions,including Australia,Canada,China,the EU,the United Kingdom,and the United States.65 Additionally,BeiGene has licensed the commercialization rights for 14 other approved drugs in the Chinese market,and established partnerships with leading biopharmaceutical companies such as Amgen and Beijing Novartis Pharma for the development and commercialization of innovative drugs.66 BeiGene boasts an extensive drug development pipeline,with approximately 50 drugs in clinical and commercialization stages:16 approved drugs(including 3 internally developed products),3 drugs in Phase 3 clinical trials,13 drugs in Phase 2,and 18 drugs in Phase 1.The company also has over 60 preclinical projects,encompassing a variety of drug types such as small molecules,monoclonal antibodies,bispecific antibodies,and ADCs.Many of these drugs have the potential to be first-in-class with differentiated mechanisms of action.BeiGenes rich and INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 24 diverse R&D pipeline broadly covers 80 percent of global cancer types by incidence.67(See figure 23.)Figure 23:BeiGenes drug development pipeline6868 BeiGene has established a comprehensive technical system that spans early discovery of anti-tumor drugs to commercialization.In the areas of small molecules,antibodies,cell therapies,and new drug production,the company has independently developed 15 core technology platforms.69 In recent years,BeiGene has received nine international awards,nominations,and honors,including the 2023 Swiss Galen Award for“Most Innovative New Anti-Tumor Drug,”the Best Star Product Award for International Innovative Drugs and Medical Devices,and the Taiwan International Innovation Award,among others.70 In terms of R&D,BeiGene positions itself as an international company.It has 45 office locations,and of its over 3,000 clinical research employees,more than 500 are located in North America and Europe.In addition to its R&D centers in Beijing and in Guangzhou,BeiGene established a clinical R&D center at the Princeton West Innovation Campus in Hopewell,New Jersey.Beyond its extensive R&D team,the company also engages in numerous collaborations and commercial development activities,relying on overseas partnerships and technologies.In 2017,BeiGene entered a collaboration with Celgene(now part of Bristol Myers Squibb).In 2019,it signed a collaboration agreement with Amgen,and in 2021,it established collaborations with Novartis.BeiGene has introduced innovative products from companies such as Amgen,Mirati,Zymeworks,SpringWorks,Seagen,Leap Therapeutics,BioAtla,and Assembly,completing the commercialization of 13 drugs in China as third-party licensed medications.71 BeiGene has established regional hubs,which serve as“regional headquarters,”around the world:in Basel,Switzerland;Beijing,China;Cambridge,Massachusetts;and San Mateo,California.The company does not have a major shareholder with a government background.Its overseas-issued shares account for 91.5 percent of its total issued shares,while domestically issued shares account for 8.46 percent of the total issued shares.The four main shareholders are INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 25 Amgen,Baker Brothers Life Sciences,L.P.;HHLR Fund,L.P.;and Capital Research and Management Company,holding 18.3 percent,11.3 percent,10.9 percent,and 7.9 percent of the shares,respectively.The largest shareholder,Amgen,is a global pharmaceutical giant,while the other three major shareholders are VC funds.Overall,the companys equity is relatively dispersed,with no single shareholder holding more than 30 percent of the shares or voting rights.72 In 2023,BeiGene received government subsidies amounting to CNY 220 million(approximately$30.8 million),which was less than 2 percent of its total annual revenue of CNY 17 billion(approximately$2.44 billion).73 In terms of R&D investment,in 2022,BeiGenes investments reached CNY 11.2 billion(approximately$1.6 billion),and increased further to CNY 12.8 billion($1.8 billion)in 2023.Over the past five years,the companys total R&D expenditure amounted to CNY 49.03 billion($6.86 billion).During the same period,its operating revenues totaled CNY 39.66 billion($5.55 billion).BeiGenes R&D efforts are primarily supported by continuous financing.In 2023,the average R&D expenditure in the industry was CNY 1.57 billion(roughly$216 million),while BeiGenes R&D investment was eight times this amount.74 BeiGene and its subsidiaries hold a total of 103 patent assets,which include 41 Chinese invention patents,58 U.S.invention patents,1 Chinese utility model patent,and 3 Chinese design patents.75 Hengrui Pharmaceuticals Jiangsu Hengrui Pharmaceuticals,known as Hengrui Pharmaceuticals,is a leading Chinese pharmaceutical company specializing in oncology,metabolic diseases,autoimmune diseases,respiratory diseases,and neurological disorders.Hengrui originated from the Lianyungang Pharmaceutical Factory established in 1970.It transitioned to a private company in 1997 and went public in 2000.The company shifted focus from generic to innovative drugs after 2008,and now has 14 self-developed and 2 co-developed novel drugs.76 Hengrui has an extensive R&D pipeline in oncology and has also made significant advances in autoimmune,metabolic,cardiovascular,infectious,respiratory,and hematological diseases,as well as pain management,neurological disorders,ophthalmology,and nephrology.77 Hengruis pipeline includes 147 projects,a 38.7 percent increase from 2023,ranking it eighth globally(being preceded by Johnson&Johnson and followed by Merck).78 Among these 147 projects,138 are originated drugs,the highest number globally.Currently,Hengrui has 13 drugs in Phase III clinical trials,10 drugs that have submitted New Drug Applications or Biologics License Applications,and 15 drugs that are either already commercialized or in the process of commercialization.79 The company has received numerous international awards.In 2023,Hengrui was listed in the Top 50 Global Pharmaceutical Companies by PharmExec magazine for the fifth consecutive year,and it ranked 13th on Informa Pharma Intelligences“Top 25 Global Pharmaceutical Companies by R&D Pipeline”list,the highest ranking ever of any Chinese pharmaceutical company.80 It was also listed in the top 10 of the Global Pharmaceutical Innovation Index by IDEA Pharma,and named one of Forbes Chinas 50 Most Innovative Companies in 2022.In 2023,the company earned revenue of$3.15 billion,marking a 7.3 percent year-on-year increase,and a net profit of$592 million,a 10 percent year-on-year increase.Revenue from innovative drugs reached$1.46 billion,the second highest among Chinese pharmaceutical companies(the highest being BeiGene).Its total R&D investment in 2023 was$850 million,INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 26 similar to the previous year,with an R&D expenditure ratio of approximately 27 percent,which had increased from$5.18 million and a R&D ratio of 4.2 percent in 2005.81 Hengrui employs over 5,000 R&D personnel and operates 14 global R&D centers,including in China,Europe,and the United States,and has conducted 60 clinical trials overseas.82 In 2023,Hengrui published 119 research achievements in academic journals,with a total impact factor of 1,394.5.83 Through independent research and external collaborations,the company has developed 16 technology platforms encompassing PROTAC,molecular glue,ADC,bispecific/multispecific antibodies,AI molecular design,T cells(i.e.,a subset of T cells that bridge innate and adaptive immunity,playing a key role in the immune system and holding promise for treating cancer),drug resistance,in-vivo pharmacology,molecular dynamics,and bioinformatics.This allows Hengrui to manage the entire drug development process,from early-stage research and translational medicine to clinical development.84 The company also maintains long-term R&D and commercialization partnerships with international pharmaceutical companies and distributors.In 2023,it secured five external transactions,with a total value exceeding$4 billion.85 For example,in February 2023,Hengrui licensed its EZH2 inhibitor for lymphoma to Treeline Biosciences in a deal worth more than$700 million.86 In August 2023,Hengrui inked a$1 billion out-licensing deal for its asthma drug with One Bio.87 In October 2023,it partnered with Merck in a deal worth up to$1.48 billion for Hengruis PARP1 trapping inhibitor and its ADC drug.88 In 2023,Hengrui received approximately$59.3 million in government subsidies,compared with$33.1 million in 2022.These subsidies primarily consisted of direct support for products,projects,and taxes.Tax incentives amounted to$5.8 million,accounting for roughly 10 percent of the total subsidies.Product-related subsidies were$41.4 million,around 70 percent of the total.Project subsidies,including government research funding for innovation projects and grants for construction projects,totalled$13.8 million,representing 20 percent of total subsidies.Government subsidies accounted for roughly 10 percent of the companys$592 million profit.89 According to the World Intellectual Property Organization,Hengrui owns 3,661 patent records.The company has filed 2,389 invention patents and 662 PCT patents.It holds 545 valid invention patents in China and 667 authorized patents in countries including the United States,EU nations,and Japan.Its patents cover new drug compounds,protein molecular structures,preparation processes,uses,and formulation compositions.90 Hengruis robust R&D pipeline,increasing R&D investments,and research partnerships demonstrate the companys commitment to biopharmaceutical innovation.CHINAS GOVERNMENT POLICIES SUPPORTING THE BIOTECH SECTOR Early Building Blocks In the 1980s,the Chinese government undertook efforts to encourage biotechnology R&D activities,launching two novel types of biotechnology centers.The first were large biotechnology bases,notably in Jiangmen and Shanghai,which aimed to bring basic research to production.The Jiangmen Single Cell Protein Biotechnology Base near Guangzhou fermented molasses into single-cell feed protein,which had applications in the food and biotechnology industries.The Shanghai Center of Biotechnology focused on areas such as genetic engineering and cell,INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 27 enzyme,and fermentation technologies,attempting to develop processing techniques for human insulin and epidermal growth factor,among others.91 The second new type of biotechnology centers was laboratories intended as national training centers for Chinese scientists.The government helped establish 11 laboratories at top biotechnology research institutions,including Peking University,Fudan University,and the Beijing Institute of Virology,among others.The technology and resources that accompanied the establishment of those labs also enabled the universities research centers to improve their facilities and equipment.For example,the building of the Laboratory of Genetic Engineering at Fudan University had positive spillovers for existing labs in the universitys Institute of Genetics,enabling collaborations between scientists and facilitating access to sophisticated laboratory instruments.92 National Biotechnology Strategy While in the past China had developed a robust manufacturing capacity primarily for small molecule drugs and vaccines,it is now seeking to become a hub of biotechnology innovation and discovery.China views biotech as a key emerging industry critical to the countrys global competitiveness,and has developed a national biotechnology strategy to bolster its industrys innovation capabilities.Since the early 2000s,Chinese government policies have shifted toward emphasizing domestic biotech innovation.93 In 2010,China launched the Strategic Emerging Industries Initiative,identifying seven industriesbiotech being one of themdeemed crucial to Chinas economic competitiveness.The Chinese government prioritized these industries,providing substantial support,and set specific milestones for them.For the biotech industry,the milestones included enhancing the originality of biotechnology by developing new technologies and products,creating a biotechnology innovation platform,and strengthening the industrialization of biotechnology through the construction of biotech high-tech parks.94 Government support has consisted of subsidies,financial incentives for innovative companies,and research grants for scientists conducting biotech-related research.Funding programs include the National High-tech R&D Program and the National Key R&D Program,which allocate resources for innovative projects.95 An industry expert explains that government support provides Chinese biotechnology companies an advantage for projects with longer time horizons.China views biotech as a key emerging industry critical to the countrys global competitiveness,and has developed a national biotechnology strategy to bolster its industrys innovation capabilities.As part of the 13th Five-Year Plan(20162020),Chinas Ministry of Science and Technology(MOST)released a Biotechnology Development Plan outlining biotech priorities and goals.These include the widespread application of genomics,development of precision medicine,and creation of gene and cell banks to be used in research.The plan emphasizes biotech as key to Chinas economic growth,supports the construction of research centers for innovative R&D and high-tech science parks,and urges industry players to enhance the originality of their drugs and devices.96 Chinas most recent Five-Year Plan(the 14th,covering 2021 to 2025),promotes the continued development and expansion of the industry,seeking to promote the integration of INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 28 biotech and IT,accelerate the development of biotech and pharmaceuticals,and increase the size and strength of Chinas bio-economy.97 While prior policy had focused on international exchange and capability development for more mature biotech sectors,Chinas most recent policies have shifted toward developing globally competitive companies and advanced biotechnology,signaling a goal to move from incremental to more radical innovations.98 MOST has played a key role in supporting Chinese biotech innovation.In 2018,it also began overseeing Chinas National Natural Science Foundation(NSFC),Chinas largest public science funding organization and a major funding source for basic research and frontier exploration,as part of a broader effort to streamline the management of domestic science and technology funding.99 In 2022,NSFC increased its research funding to encourage exploration and innovation,awarding 51,600 grants for a total of CNY 32.699 billion(nearly$4.5 billion),up from CNY 31.2 billion($4.2 billion)in 2021.100 The creation of a national biotechnology strategy,which provides support and incentives for government,academia,and industry to all work for the common goal of advancing biotech innovation,has been critical for Chinas biotech advances,encouraging the industry to shift from“Made in China”to“Created in China.”Chinas government has also promoted public-private partnerships,particularly collaborations with academia and industry on biotech research projects and technology commercialization.One example is the Tianjin Institute of Industrial Biotechnology of the Chinese Academy of Sciences(CAS),a national research institute established by CAS and the Tianjin Municipal Government in 2012.The institute was equipped with sophisticated facilities for high-throughput screening,systems biotechnology,fermentation,and genome synthesis.101 Another example is the government-funded China National GeneBank,established as a repository of genetic data to spur genomics research.102 The creation of a national biotechnology strategy,which provides support and incentives for government,academia,and industry to all work for the common goal of advancing biotech innovation,has been critical for Chinas biotech advances,encouraging the industry to shift from“Made in China”to“Created in China.”High-Tech Parks The Chinese government has also supported the construction of high-tech science parks to support biotech development.These parks provide biotech companies with infrastructure,lab space,resources,talent pools,and financial support,including access to VC funding.Examples include the Zhangjiang Hi-Tech Park in Shanghai,Zhongguancun Life Science Park in Beijing,and BioBay in Suzhou.Biobay,for example,provides nanotechnology platform services to 51 companies,and supports companies with regulatory filings and financing.103 Such parks are especially critical for resource-constrained start-ups that cannot build their own expensive R&D facilities due to the massive up-front investments required and the high risks associated with drug R&D.A subtle but important factor that has supported Chinas fledgling biotech industry has been a shift in cultural attitudes toward entrepreneurship.Entrepreneurship was not previously viewed positively in China,and start-ups were not allowed during the countrys Mao era(1950s1970s)due to being considered“sprouts of capitalism.”104 But in recent years,entrepreneurship has increasingly been seen as an important force of economic growth.As such,INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 29 the Chinese government has implemented a number of initiatives to foster entrepreneurship,including the creation of high-tech parks and start-up incubators to support them.105 The emergence of a new type of organization in the 1990s,known as the contract research organization,has also spurred the development of Chinas biotech industry.106 CROs provide a wide variety of research services to biotech companies.In recent years,these services have shifted from technology transfer and customized production to a more cooperative R&D model between companies and CROs.107 Baeder explains that while early Chinese CROs were not very sophisticated,recently,high-quality,innovative,local CROs have emerged,with a wide range of capabilities including running clinical trials.In fact,China has become an ideal locale for clinical trials,due to high speed and low costs,and trials that used to be conducted in Europe were already moving to China prior to the U.S.governments efforts to discourage firms from using this avenue to accelerate development.108 A study of 66 CROs finds that many of them are located among biotech companies in high-tech parks,where they can leverage the parks infrastructure,incubators,R&D facilities,and government support.The agglomeration offered by high-tech parks,pooling scientific expertise,state-of-the-art technological facilities,biotech companies,incubators,and financial resources,supports the development of CROs,which in turn spurs biotech innovation.109 Nowadays,CROs and contract development and manufacturing organizations provide services ranging from discovery biology and preclinical research through biologics manufacturing at both clinical and commercial volumes.For instance,BioBay Park,built in 2006 in Suzhou,has over 360 companies.Its CROs provide chemistry synthesis,reagent provisioning,and gene synthesis and sequencing services to these companies.The bioinformatics company Genewiz is one example of a CRO located in BioBay Park.The agglomeration offered by high-tech parks,pooling scientific expertise,state-of-the-art technological facilities,biotech companies,incubators,and financial resources,supports the development of CROs,which in turn spurs biotech innovation.Regulatory Environment China has also been initiating regulatory reforms to streamline its drug and device review processes.The reforms are in response to challenges that have hindered access to innovative drugs,such as overly strict requirements for clinical trial approvals,long regulatory review times,and a shortage of reviewers.110 In 2017,Chinas NMPA,its equivalent of the FDA,joined the International Council for Harmonisationwhose role is to ensure that effective and safe medicines reach patients in the most resource-efficient way around the worldas a regulatory member,and began focusing on fast approval of innovative therapeutics.111 NMPA introduced expedited pathways for the review of biotech products and has substantially increased its staff to speed up review processes.112 A recent study exploring the impact of these reforms on drug review times analyzed 344 NMPA approvals(for small molecule drugs,biologics,and vaccines)between 2011 and 2021.Overall,INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 30 the median approval time for all drugs decreased from 22.1 months in the period 20112013 to 15.4 months in 20172021.For small molecule drugs,review time decreased from 20.4 to 15.7 months,while for biologics,it decreased even more,from 21.3 to 14.2 months.Between 20112013 and 20172021,drug review times decreased more for domestic than for imported drugs:from a median of 19.9 to 14.5 months for imported drugs,and from 32.5 to 16.7 months for domestic drugs,representing a 27 percent and a 49 percent decrease,respectively.113 Baeder notes that the difference in drug approvals between imported and domestic drugs owes mainly to the fact that imported drugs,which typically already had U.S.FDA approval,a track record of safety in other markets,and strong clinical data,were safer bets than domestic drugs for NMPA reviewers.As part of recent regulatory reforms,NMPA announced that any filing that falsified data would automatically be rejected and the entire filing process must be restarted from the beginning.Following the announcement,86 percent of filings were voluntarily withdrawn before the NMPA deadline.This reform helped improve the quality and credibility of Chinese companies data,reducing reviewers workload and accelerating domestic approvals.IP Protection China has also been undertaking reforms to strengthen IP rights and enforcement to incentivize innovation.Compared with the United States,China has had a weaker IP environment for life sciences innovation,and historically shorter patent terms that enabled domestic companies to copy the drug discoveries of more innovative foreign companies.The United States provides a five-year data exclusivity period(a time during which regulatory authorities cannot rely on innovators clinical trial data to approve generic drugs)for new chemical entities(NCEs,small molecule drugs)and 12 years for biologics.These measures seek to incentivize innovation by granting exclusive use of clinical trial data submitted to the FDA by the innovator.In China,the regulatory landscape has been evolving over the past few years.Existing regulations allow six years for NCEs,but do not include biologics.NMPA has published multiple versions of a draft guidance that proposes keeping the data exclusivity period of 6 years for NCEs and establishing a period of 12 years for biologics.114 However,at the time of this writing,the draft guidance has not been enacted,and has been in a“draft for comment”status for the last two years,with a lack of practical guidelines in implementation,and only NCEs remain eligible for regulatory data protection.115 In June 2021,China further updated its patent laws,implementing several significant revisions designed to encourage pharmaceutical companies to develop and seek approval for novel drugs in China.Two notable revisions involve the introduction of a new patent linkage system and a patent term extension(PTE)mechanism for certain types of pharmaceutical patents.Patent linkage has been in operation for almost three years,but PTEs have not yet been fully implemented.116 Such changes to Chinas IP protection regime,and the countrys desire to harmonize its IP environment with other developed regimes,illustrate its efforts to achieve a more robust patent system supportive of biotechnology innovation.IP Theft There have been many reports of Chinese biomedical researchers working at U.S.universities,often on NIH grants,and taking the IP that their labs develop back to China.117 For example,in 2020,the U.S.Department of Justice charged the chair of Harvard Universitys Chemistry and Chemical Biology Department,Charles Lieber,with aiding China with“one count of making a INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 31 materially false,fictitious and fraudulent statement”regarding his work with organizations tied to the Chinese government,while on NIH funding.118 Also in 2020,Ohio citizen Yu Zhou was sentenced to prison for conspiring to steal trade secrets concerning the research and treatment of different medical conditions,including cancer,from Nationwide Childrens Hospitals Research Institute to sell to China.119 Moreover,Chinese state-sponsored actors have targeted biopharma firms for IP theft,including through cybertheft and rogue employees.120 That theft is sometimes through direct means whereby scientists working at U.S.biopharma companies engage in IP theft and then transfer it to China.In 2018,Yu Xue,a leading biochemist working at a GlaxoSmithKline research facility in Philadelphia,admitted to stealing company secrets and funneling them to a rival firm,Renopharma,a Chinese biotech company funded in part by the Chinese government.121 In October 2023,intelligence chiefs from the Five Eyes countriesthe United States,Britain,Canada,Australia,and New Zealandaccused China of IP theft in sectors including biotechnology.122 Scientific Talent China has invested significant resources in STEM education,as well as talent development and recruitment efforts,to nurture a strong biotech workforce.One effort was the Chinese Ministry of Educations China-United States Biochemistry Examination and Application(CUSBEA)program,which ran between 1981 and 1989.Its goal was to train young Chinese scientists in biochemistry and molecular biology at U.S.universities,with the expectation that they would return home to advance their respective fields.More than 400 students attended Ph.D.programs at U.S.universities throughout the program.123 From 1985 to 2005,through CUSBEA and other means,Chinese scientists earned 12,000 Ph.D.degrees in life-sciences disciplines at American universities.124 The Chinese government has implemented several talent recruitment efforts to attract them to return to China.One effort,the National Science Fund for Distinguished Young Scholars,has supported scientists to pursue basic research projects,given that they work in their home institutions in China for at least nine months a year.125 Another effort,a program run through the China Scholarship Council,a subsidiary of the Ministry of Education,has provided funding to students from top Chinese universities to pursue Ph.D.s at universities in the United States,Canada,the United Kingdom,and Australia,especially in the life sciences.Recipients must return to China after finishing their studies.126 Such initiatives,while not limited to China,seek to enhance the countrys domestic research and innovation capacity.According to the National Bureau of Statistics of China,the number of Chinese students returning from abroad steadily increased from 108,300 returnees in 2009 to 580,300 in 2019.127 And,in total,according to the Ministry of Education of China,out of nearly 6.6 million young Chinese who studied abroad since 1978,over 4.23 million(86 percent)have chosen to return home and work in academia or industry in China.128 This is creating a brain drain for the United States,and a brain gain for China,especially in certain therapeutic areas such as cancer and neurology.In an interview published on Medium,Duane Schulthess,CEO of Vital Transformation,a health economics consulting firm,noted that“what youre seeing is a transition to advanced therapies.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 32 In 2018,in China,there were 240 CAR-T developments,there were 140 in the United States,there were 40 in Europe China is focusing on the advanced sciences because all the Chinese students who used to come to the United States,and go to Stanford and Berkeley and Harvard and MIT now are going back.”129 Returnees are attracted to,among other factors,both the resources and capital available through the Chinese governments support of the biotech industry and increasing amounts of VC funding.130 Moreover,the annual number of STEM Ph.D.s who graduated from universities in China has surpassed those graduating in the United States.In 2000,U.S.universities awarded more than twice as many STEM doctoral degrees as Chinese universities.More than half of those U.S.degrees(62 percent)were awarded to domestic students.And Chinese students comprise the largest share of non-domestic U.S.STEM Ph.D.s.131 By 2007,the number of STEM doctorates awarded by Chinese universities exceeded that from American universities.In 2019,China awarded 49,498 STEM Ph.D.degrees,while the United States awarded 33,759.132(See figure 24).Figure 24:STEM Ph.D.graduates,United States and China133 Price Controls Drug reimbursement in China has become increasingly centralized through the establishment of the National Healthcare Security Administration and the implementation of the National Reimbursement Drug List(NRDL),where drug price negotiation takes place.134 China has been imposing steep drug price controls and favoring Chinese firms in national drug selection,seeking to build up its domestic industry capabilities.135 For example,in 2022,as in 2021,Chinese domestic companies were the source of most new drugs added to the 2022 NRDL,with some MNCs continuing to struggle to make deals with 010,00020,00030,00040,00050,00060,00020002005201020152020Chinese STEM PhDs(total)U.S.STEM PhDs(total)U.S.STEM PhDs(domestic)INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 33 NHSA for their drugs.In 2022,out of 147 drugs negotiated,121 were added to the 2022 NRDL,with an average price cut of 60.1 percent.Seven orphan drugs were included in the 2022 NRDL,but the prices of those reimbursed drugs were far lower than their prices in other countries,with some reaching discounts of 94 percent during NRDL negotiation.136 These price controls hurt foreign firms more than Chinese firms with lower cost structures,and reduce the revenues of the global drug discovery innovation system.137 China has been imposing steep drug price controls and favoring Chinese firms in national drug selection,seeking to build up its domestic industry capabilities.WHAT SHOULD AMERICA DO?The United States has developed a sophisticated ecosystem supporting biotechnology innovation.This ecosystem is composed of national funding sources,VC/PE start-up funding,large pharmaceutical firms supporting and conducting life sciences R&D,strong IP protection,and robust commercialization ability.A scientist quoted in the 2021 book Demystifying Chinas Innovation Machine commented,“Commercial transformation ability is completely different from scientific research ability No place in the world can be compared with Cambridge,where a complete ecosystem supports R&D and commercialization of biotechnology.”138 An industry expert explains that this ecosystem is crucial to the success of the industry,and that it will take time before we see an industry in China on par with the one in the United States.Yet,the emergence of Chinese biohubs,such as the Bohai Rim Cluster,the Yangtze River Cluster,the Mid-West Cluster,and the South China Cluster,mentioned previously,suggests that China is actively establishing the infrastructure necessary to develop such ecosystems.ITIF has previously laid out a comprehensive set of policies to stimulate U.S.biopharmaceutical innovation through reports such as“Ensuring U.S.Biopharmaceutical Competitiveness.”139 While this report doesnt recount all those policy recommendations,it does highlight several measures that would help the United States nurture its robust and unique ecosystem to maintain its global biotechnology leadership.These include restoring a more supportive policy environment,expanding efforts to strengthen domestic supply chains for essential medical ingredients,improving the IP system to incentivize long-term medical research,providing federal R&D investments,and limiting government drug price control schemes.A June 2024 study shows that proposed U.S.policies to reduce pharmaceutical prices,while beneficial at present for low-income populations,would cause a roughly 20 percent decrease in pharmaceutical firms net profits,which in turn would reduce their future drug R&D investments.140 The stark reality is that if the United States continues down the path of strict drug price controls,its lead over China will continue to shrink,if not evaporate.The United States should also expand policies that spur greater domestic innovation,such as boosting R&D funding through bodies such as NIH and ARPA-H,expanding investment incentives for biopharmaceutical companies,and supporting data-driven drug development through greater data availability and secure data sharing among global biopharmaceutical stakeholders.Two factors that could help achieve this are good data-sharing policies and the use of privacy-enhancing technologies(PETs),which help improve privacy protection and promote secure collaborative research.Several steps have been taken in this direction.In October 2023,the INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 34 White House issued an executive order,“Advancing a Vision for Privacy-Enhancing Technologies,”which called for the design,development,and deployment of PETs.And in April 2024,a new bill,the“Privacy Enhancing Technology Research Act,”which would require NSF to support R&D of PETs and direct federal agencies to accelerate their development,deployment,and adoption,passed the House.It currently stands for consideration in the Senate.Implementing such policies could help support data-driven drug development.Further,when examining investment incentives for U.S.domestic innovation,it is also crucial to consider policies that ensure beneficiary access.For example,in the landscape of genomic innovations for early cancer detection,the lack of meaningful coverage pathways significantly inhibits U.S.innovation and competition.141 Congress should pass the MCED Screening Coverage Act,which seeks to address these gaps in access and support the development and deployment of such innovations.142 The United States should also support policies to spur increased domestic production,including supporting R&D for biopharmaceutical process innovation,increasing funding for biomedical manufacturing centers,providing financial support for the establishment of new domestic biomedical production facilities,and expanding incentives for domestic manufacturing to mitigate vulnerabilities in biopharmaceutical supply chains and enhance national security.143 The National Institute for Pharmaceutical Technology and Education,a research-and education-based academic organization,stresses that the critical elements of a comprehensive strategy for reshoring pharmaceutical manufacturing include innovation in advanced manufacturing,pharmaceutical“new prior”knowledge(i.e.,a synthesis of the existing prior knowledge from the time the original drug was approved with the new,state-of-the-art technologies),and training and education of pharmaceutical scientists,engineers,and manufacturing workforce.In particular,to facilitate reshoring the supply chain employing new technologies,it is essential to support the design and development of materials and products and continuous manufacturing processes.144 Moreover,while differences exist between the biotechnology and semiconductor industries,the United States should support the passage of legislation similar to the CHIPS Act for the biopharmaceutical industry,including allocating at least$5 billion to states to provide incentives for the establishment of new biomedical production facilities in the United States,and supporting the launch of a joint industry-university-government R&D partnership to reduce the cost of drug development and production.New technologies,such as AI and quantum computing,have the potential to lower the cost of drug discovery and production,and funding for an R&D program to support the development of such technologies,such as the R&D program established under the CHIPS legislation,could support biopharmaceutical advances.145 On the last point,proposed legislation known as the BIOSECURE Act aims to protect U.S.national security by limiting the involvement of certain foreign biotechnology companies in U.S.government contracts and research collaborations.The act would prohibit federal agencies from contracting with or extending loans or grants to any company engaging with a“biotechnology company of concern”those connected to foreign adversaries deemed to pose a security risk to U.S.national security due to their ties with such governments.The bill specifically names several Chinese biotechnology companies,including BGI,MGI,Complete Genomics,and WuXi Apptec,as companies of concern.146 It will take time for U.S.entities to move away from working with Chinese contract biomanufacturing organizations to find new partners and build up their own INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 35 capabilities,but the bill does mean that the United States is beginning to decouple Americas dependence on China in order to advance national security and public health interests.CONCLUSION The Chinese government has devised a comprehensive national strategy to advance the innovativeness of its biotechnology industry,which it views as crucial for economic growth and national competitiveness.The plan aims to turn China into a world leader in the industry.The strategy includes subsidies;financial incentives;the initiation of national reimbursement for innovative therapies;the establishment of high-tech science parks,start-up incubators,and public-private partnerships;talent recruitment initiatives;reforms to expedite drug review,especially for domestic products;and efforts to enhance IP protection to foster innovation.Chinas biopharmaceutical industry is starting to show signs of innovation,including a surge in the volume and quality of biotech-related scientific publications,a rise in the number of novel Chinese drugs and out-licensing deals from Chinese biotech companies,and an increase in clinical trials taking place in China.But despite Chinas biotechnology advances,the country still faces several challenges.Many Chinese start-ups are founded by scientists,which presents difficulties for commercialization,as scientific research ability is very different from commercial transformation ability.Reflecting on the state of technology entrepreneurship in China,Marina Tue Zhang,Mark Dodgson,and David M.Gann wrote in their 2021 book,Demystifying Chinas Innovation Machine,“There is a long distance from lab to hospital and pharmacy.Supportive policy,capital,and experienced managers are needed to make it,which also depend on mature ecosystems that China does not possess.The United States,on the other hand,has a sophisticated biopharmaceutical ecosystem,not only in life science R&D but also in the commercialization of biotechnology and bioengineering breakthroughs,and in strong IP protection.”147 For China to become a global biotech leader,it will be critical for it to build comprehensive ecosystems,which include greater enforcement of IP rights,ethical use of technologies such as gene editing,and technology transfer from research to industry to enhance commercialization capabilities.148 INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 36 Acknowledgments ITIF wishes to thank the Smith Richardson Foundation for supporting research on the question,“Can China Innovate?”Other reports in this series will cover artificial intelligence,electric vehicles and batteries,chemicals,nuclear power,quantum computing,robotics,and semiconductors(Search#ChinaInnovationSeries on itif.org.).The author would like to thank Robert Atkinson,Stephen Ezell,Ian Tufts,and Chongyi Zhang for their assistance with this report.Any errors or omissions are the authors responsibility alone.About the Author Sandra Barbosu,Ph.D.,is senior policy manager in the Economics of Biopharmaceutical Innovation at ITIFs Center for Life Sciences Innovation.Her research focuses on the economics of innovation,particularly the role of emerging technologies in health care.Sandra is also adjunct professor at New York Universitys Tandon School of Engineering.She holds a Ph.D.in Strategic Management from the Rotman School of management at the University of Toronto,and an M.Sc.in Precision Cancer Medicine from the University of Oxford.About ITIF The Information Technology and Innovation Foundation(ITIF)is an independent 501(c)(3)nonprofit,nonpartisan research and educational institute that has been recognized repeatedly as the worlds leading think tank for science and technology policy.Its mission is to formulate,evaluate,and promote policy solutions that accelerate innovation and boost productivity to spur growth,opportunity,and progress.For more information,visit itif.org/about.ENDNOTES 1.“Gregor Mendel,”Britannica,accessed May 30,2024,https:/ 2.Susan Borowski,“The other discoverers of DNA,”American Association for the Advancement of Science(AAAS),April 25,2013,https:/www.aaas.org/other-discoverers-dna.3.Troy Segal,“Biotechnology vs.Pharmaceuticals:Whats the Difference?”Investopedia,April 19,2023,https:/ Ma.“Biotechnologies in China:A state of play,”Fondation pour LInnovation Politique,February 2020,https:/www.fondapol.org/app/uploads/2020/06/etude-ma-aifang-fondapol-biotech-chine-va-2020-02-25-3.pdf.5.Xiaodang Tan,Xiangxiang Liu,and Haiyan Shao,“Health China 2030:A Vision for Health Care,”Values in Health Regional Issues(2017)12C:112114,https:/www.ispor.org/docs/default-source/publications/newsletter/commentary_health-care_china_2030.pdf.6.Sandra Barbosu,“Not Again:Why the United States Cant Afford to Lose Its Biopharma Industry”(ITIF,February 2024),https:/itif.org/publications/2024/02/29/not-again-why-united-states-cant-afford-to-lose-biopharma-industry/.7.Clayton M.Christensen,Michael E.Raynor,and Rory McDonald,“What is Disruptive Innovation?”Harvard Business Review,December 2015,https:/hbr.org/2015/12/what-is-disruptive-innovation.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 37 8.Scott M.Moore,Practice Professor of Political Science,University of Pennsylvania,and George Baeder,a biotech executive with 30 years of experience in China,gave us permission to be named in the report.9.“What is Biotechnology?”Biotechnology Innovation Organization(2024),https:/www.bio.org/what-biotechnology 10.Praveen Sharma and Shailendra Dwivedi,“Prospects of Molecular Biotechnology in Diagnostics:Step Towards Precision Medicine,”Indian Journal of Clinical Biochemistry,vol.32(2017):121123,https:/doi.org/10.1007/s12291-017-0650-9.11.Gary Walsh,“Biopharmaceutical benchmarks 2018,”Nature Biotechnology,vol.36(2018),11361145,https:/ A.Doudna and Emmanuelle Charpentier,“The new frontier of genome engineering with CRISPR-Cas9,”Science,vol.346,no.6213(2014),https:/doi.org/10.1126/science.1258096.13.David Ricks,“Building an Innovation Ecosystem for a Healthier and More Secure Future”(PhRMA,January 28,2022),10,http:/www.phrma-jp.org/wordpress/wp-content/uploads/2022/01/220128_PhRMA_Press_Conference_Presentation_ENG.pdf.Citing:IQVIA Institute for Human Data Science,“Global Trends in R&D:Overview Through 2020”(IQVIA,May 2021),https:/ Barbosu,“Not Again:Why the United States Cant Afford to Lose Its Biopharma Industry”(ITIF,March 2024),https:/www2.itif.org/2024-losing-biopharma-leadership.pdf.14.“China biopharma Charting a path to value creation,”McKinsey&Company,November 2023,accessed May 10,2024,https:/ Academy of Sciences(US)Committee on Scholarly Communication with the Peoples Republic of China,Hamer DH,Kung S,editors,Washington(DC):National Academies Press(US)(1989),Ch.2,Chinas Long History of Biotechnology,https:/www.ncbi.nlm.nih.gov/books/NBK236111/.16.“Biotechnologies in China:A state of play.”17.National Science Foundation,Science&Engineering Indicators,Production and Trade of Knowledge-and Technology-Intensive Industries,Table SKTI-9:Value added of pharmaceuticals industry,by region,country,or economy:200219;accessed May 5,2024,https:/ncses.nsf.gov/pubs/nsb20226/data.18.“Biotechnologies in China:A state of play.”19.“China biopharma Charting a path to value creation,”McKinsey&Company.20.Phone conversation with Scott M.Moore,Practice Professor of Political Science,University of Pennsylvania,April 2,2024.21.Ling Su et al.,“Trends and Characteristics of New Drug Approvals in China,20112021,”Therapeutic Innovation&Regulatory Science,vol.57(2023):343351,https:/doi.org/10.1007/s43441-022-00472-3.22.Ibid.23.Ibid.24.Lang Zheng,Wenjing Wang,and Qiu Sun.“Targeted drug approvals in 2023:breakthroughs by the FDA and NMPA,”Signal Transduction and Targeted Therapy,vol.9,no.46(2024),https:/doi.org/10.1038/s41392-024-01770-y.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 38 25.Lang Zheng et al.,“Targeted drug approvals in 2023:breakthroughs by the FDA and NMPA”;“FDA approves toripaliman-tpzi for nasopharyngeal carcinoma,”FDA,accessed May 5,2024,https:/www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-toripalimab-tpzi-nasopharyngeal-carcinoma;“FDA approves fruquintinib in refractory metastatic colorectal cancer,”FDA,accessed May 5,2024,https:/www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-fruquintinib-refractory-metastatic-colorectal-cancer;“FDA Approves Ryzneuta,”D,accessed May 5,2024,https:/ R&D:Annual Review 2024:Insights from our annual review of trends in pharmaceutical R&D,”Citeline Clinical,January 2024,https:/ R&D Annual Review 2023,”Citeline Clinical,April 2023,https:/ R&D Annual Review 2021,”Citeline Informa Pharma Intelligence,February 2021,https:/ R&D Annual Review 2020,”Pharma Intelligence Informa,March 2020,https:/ R&D Annual Review 2019”Pharma Intelligence Informa,February 2019,https:/ R&D Annual Review 2018,”Pharma Intelligence Informa,February 2018,https:/.tw/wp-content/uploads/2018/07/Pharma-RD-Review-2018-Whitepaper-Final含公司資料.pdf 27.Ibid.28.Zoom conversation with George Baeder,a biotech executive with 30 years of experience in China,April 22,2024.29.“China biopharma Charting a path to value creation,”McKinsey&Company,November 2023,accessed May 10,2024,https:/ Gardner,“Roche pays China-based biotech$70M for a new HER2 drug,”Biopharma Dive,May 9,2023,accessed May 10,2024,https:/ announces collaboration with Novartis to develop and commercialize anti-PD-1 antibody tislelizumab,”BeiGene Press Release,January 11,2021,accessed May 10,2024,https:/ and Regor Therapeutics Group Enter into Strategic Collaboration to Discover and Develop Novel Therapies for Metabolic Disorders,”Eli Lilly Press Release,December 10,2021,accessed April 30,2024,https:/ enters exclusive license agreement with Hansoh for HS-20093,”GSK Press Release,December 20,2023,accessed July 15,2024,https:/ TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 39 37.“SeekIn and OncoInv Collaborate to Expand the Global Accessibility of Multiple Cancer Detection Tests and Bridge Global Disparities in Cancer Care,”PR Newswire,December 13,2023,accessed May 1,2024,https:/ Wang et al.,“A sustainable approach to universal metabolic cancer diagnosis,”Nature Sustainability,vol.7(2024):602615,https:/ conversation with George Baeder,a biotech executive with 30 years of experience in China,April 22,2024.40.“Evolution of Clinical Trials in the Asia Pacific Region Compared to the US and the EU5,”GlobalData and Novotech,The Asia Pacific CRO,April 2022,https:/novotech- Transformation,“Growth in Chinese Alzheimers Clinical Trials”(2023),data source:https:/ Institute for Human Data Science,“Global Trends in R&D 2024,”Exhibit 11(IQVIA,February 2024),https:/ Data Explorer,Bibliometric indicators,by field(Fractional counts of scientific publications among the worlds 10%top-cited scientific publications,Biotechnology,2008,2022),https:/data-explorer.oecd.org/.49.OECD Data Explorer,Bibliometric indicators,by field(Scientific publications among the worlds 10%top-cited scientific publications,Percentage of scientific publications in the same subgroup,Biotechnology 2008,2022),https:/data-explorer.oecd.org/.50.“Critical Technology Tracker,”Biological manufacturing,Australian Strategic Policy Institute(ASPI),accessed May 7,2024,https:/techtracker.aspi.org.au/tech/biological-manufacturing/?c1=cn.51.Ibid.,5.52.Critical Technology Tracker,”Genome and genetic sequencing and analysis,Australian Strategic Policy Institute(ASPI),accessed May 7,2024,https:/techtracker.aspi.org.au/tech/genome-and-genetic-sequencing-and-analysis/?c1=cn.53.Ibid.,7.54.“Critical Technology Tracker,”Genetic engineering,Australian Strategic Policy Institute(ASPI),accessed May 7,2024,https:/techtracker.aspi.org.au/tech/genetic-engineering/?c1=cn.55.Ibid.,9.56.“Critical Technology Tracker,”Novel antibiotics and antivirals,Australian Strategic Policy Institute(ASPI),accessed May 7,2024,https:/techtracker.aspi.org.au/tech/novel-antibiotics-and-antivirals/?c1=cn.57.Ibid.,11.58.WIPO,“Patent Cooperation Treaty(PCT),”https:/www.wipo.int/treaties/en/registration/pct/.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 40 59.World Intellectual Property Organization(WIPO),WIPO statistics database(5a-PCT publications by technology;Biotechnology;1995,2023),accessed May 7,2024,https:/www3.wipo.int/ipstats/ips-search/patent.60.Ibid.,14.61.National Science Foundation,Science&Engineering Indicators(Production and Trade of Knowledge-and Technology-Intensive Industries,Table SKTI-24:Total biotechnology venture capital raised,by selected country and region:200020),accessed May 13,2024,https:/ncses.nsf.gov/pubs/nsb20226/data.62.Ibid.63.Rob Wright,“How And Why John Oyler Built BeiGene,”Life Science Leader,November 1,2019,accessed July 15,2024,https:/ R&D,”BeiGene,accessed May 30,2024,https:/ 2023 Annual report”,accessed June 1,2024,https:/ 66.Ibid.67.Ibid.68.“Our R&D,”BeiGene.69.“BeiGene 2023 Annual report.”70.“BeiGenes Baiyueze won the Swiss Galen Prize,”ECHEMI,June 8,2023,accessed May 30,2024,https:/ 2023 Annual report.”72.Ibid.73.Ibid.74.“BeiGene Annual report,”2018-2023,https:/ result from WIPO,accessed May 30,2024,https:/www.wipo.int/search/en.76.“Jiangsu Hengrui Pharmaceuticals 2023 Annual Report,”accessed June 20,2024,https:/ and Innovate,”Jiangsu Hengrui Pharmaceuticals Website,accessed June 10,2024,https:/ R&D Annual Review 2024 Supplement:New Active Substances Launched During 2023,”Citeline:Clinical,accessed June 15,2024,https:/ 79.Ibid.80.“Jiangsu Hengrui Pharmaceuticals 2023 Annual Report.”81.“Jiangsu Hengrui Pharmaceuticals Annual Report,”2005,20202023,accessed June 8,2024,https:/ Hengrui Pharmaceuticals Website,accessed June 15,2024,https:/ TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 41 84.Ibid.85.Ibid.86.Zhang Mengying,“Hengrui licenses EZH2 inhibitor to Treeline in$700M deal,”BioWorld,February 14,2023,accessed July 15,2024,https:/ inks$1B out-licensing deal for asthma drug with One Bio,”August 22,2023,BioWorld,accessed July 15,2024,https:/ Barrie,“Merck partners with Hengrui in deal worth up to$1.48bn,”Pharmaceutical Technology,October 30,2023,accessed July 15,2024,https:/www.pharmaceutical- Hengrui Pharmaceuticals Annual Reports,”2022-2023,accessed June 15,2024,https:/ result from WIPO,accessed June 10,2024,https:/www.wipo.int/search/en.91.National Academy of Sciences(US)Committee on Scholarly Communication with the Peoples Republic of China,Hamer DH,Kung S,editors,Washington(DC):National Academies Press(US)(1989),Ch.4,New Research Centers.92.Ibid.93.Marina Zhang,Mark Dodgson,and David Gann,“Chinas Innovation Machine,”Demystifying Chinas Innovation Machine:Chaotic Order,online edition,Oxford University Press(2021),https:/doi-org.proxy.library.nyu.edu/10.1093/oso/9780198861171.003.0001.94.“China Government Initiatives in Biotechnology,”Global X by Mirae Asset,February 2020,https:/.hk/content/files/China_Government_Initiatives_in_Biotechnology.pdf 95.“S&T Programs,”Ministry of Science and Technology of the Peoples Republic of China,accessed May 24,2024,https:/ Government Initiatives in Biotechnology.”97.“Outline of the Peoples Republic of China 14th Five-Year Plan for National Economic and Social Development and Long-Range Objectives for 2035,”Translation,Center for Security and Emerging Technology(CSET),https:/cset.georgetown.edu/wp-content/uploads/t0284_14th_Five_Year_Plan_EN.pdf.98.Zhang et al.,“Chinas Innovation Machine,”Demystifying Chinas Innovation Machine:Chaotic Order.99.Scott Moore,“Chinas Role in the Global Biotechnology Sector and Implications for U.S.Policy,”Global China:Assessing Chinas Growing Role in the World,Brookings Institution,April 2020,https:/www.brookings.edu/wp-content/uploads/2020/04/FP_20200427_china_biotechnology_moore.pdf;“NSFC at a Glance,”National Natural Science Foundation of China(2017)http:/ Yu,“2022 Annua Report,”National Natural Science Foundation of China,https:/ science foundation ups research budget to 33b yuan,”The State Council The Peoples Republic of China,accessed July 8,2024,https:/ TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 42 101.“TIB China,”Tianjin Institute of Industrial Biotechnology,China,Commission on Science and Technology for Sustainable Development in the South(COMSATS),accessed May 20,2024,https:/comsats.org/tib-china/.102.“China National GeneBank DataBase(CNGBdb),”accessed May 25,2024,https:/gb.org.103.“China Government Initiatives in Biotechnology,”Global X by Mirae Asset.104.Siu-Lun Wong.“Creative Destruction:The Rise of Entrepreneurial Society in China,”Les socits Entrepreneuriales et Les Mondes Anglophones,edited by Jacques-Henri Coste,Presses Sorbonne Nouvelle(2013)https:/doi.org/10.4000/books.psn.7855.105.Zhang et al.,“Technology Entrepreneurship,”Demystifying Chinas Innovation Machine:Chaotic Order.106.Yun-Zhen Shi,Hao Hu,and Chunming Wang,“Contract Research Organizations(CROs)in China:integrating Chinese research and development capabilities for global drug innovation,”Globalization and Health,vol.10:(2014),https:/ et al.,“Technology Entrepreneurship,”Demystifying Chinas Innovation Machine:Chaotic Order.108.Zoom conversation with George Baeder,a biotech executive with 30 years of experience in China,April 22,2024.109.Christine Xia and Ajay Gautam,“Biopharma CRO industry in China:landscape and opportunities,”Drug Discovery Today,vol.20,no.7(2015):794-798,https:/ Su et al.,“Trends and Characteristics of New Drug Approvals in China,20112021.”111.Jessica Zhou,“China Focusing Innovation Through ICH Global Regulatory Vision,”June 2,2017,https:/globalforum.diaglobal.org/issue/august-2021/china-focusing-innovation-through-ich-global-regulatory-vision/.112.“China Government Initiatives in Biotechnology,”Global X by Mirae Asset.113.Ling Su et al.,“Trends and Characteristics of New Drug Approvals in China,20112021.”114.“China Drug Administration published a key Draft Guidance on data exclusivity,”May 8,2018,accessed July 8,2024,https:/ Draft Implementing Regulations propose key changes for pharmaceuticals in China,”May 19,2022,Bird&Bird,accessed July 8,2024,https:/ Chinas new patent linkage and patent extension systems mean for foreign pharma,”Hogan Lovells,July 26,2023,accessed July 15,2024,https:/ D.Atkinson,“The Impact of Chinas Policies on Global Biopharmaceutical Industry Innovation”(ITIF,September 2020),https:/itif.org/publications/2020/09/08/impact-chinas-policies-global-biopharmaceutical-industry-innovation/;Lawrence Tabak and Roy Wilson,“Foreign Influences on Research Integrity”(presented at the 117th meeting of the advisory committee to the director,NIH,December 13,2005),https:/acd.od.nih.gov/documents/presentations/12132018ForeignInfluences.pdf.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 43 118.Alex Keown,“Harvard Professor Arrested as Government Continues to Crack Down on Researchers Financial Ties to China,”BioSpace,January 29,2020,https:/ Rapoza,“To Build Chinas Biotech,Just Keep Stealing:DoJ Jails Two For Spying,”Prosperous America,April 23,2021,accessed July 15,2024,https:/prosperousamerica.org/china-ip-theft-in-ohio/.120.Office of the United States Trade Representative Executive Office of the President,Update Concerning Chinas Acts,Policies,and Practices Related to Technology Transfer,Intellectual Property,and Innovation(Washington,D.C.:USTR,November 2018),11,https:/ustr.gov/sites/default/files/enforcement/301Investigations/301 Report Update.pdf.121.Jeremy Roebuck,“Chinese American scientist admits plot to steal GlaxoSmithKlines secrets for firm in China,”The Philadelphia Inquirer,August 31,2018,http:/ Siddiqui,“Five Eyes intelligence chiefs warn on Chinas theft of intellectual property,”Reuters,October 18,2023,accessed July 10,2024,https:/ Chang,“The CUSBEA program:Twenty years after,”IUBMB Life,26 May 2009 https:/ and Engineering Indicators 2008,National Science Board(2008):http:/www.nsf.gov/statistics/seind08/.125.“National Science Fund for Distinguished Young Scholars,”accessed May 5,2024,https:/ in China:30 Years On,”Cell,vol.134(2008):375377,https:/ of Chinese students returning from abroad from 2009 to 2019(in 1,000s),”National Bureau of Statistics of China,October 9,2021,In Statista,accessed May 24,2024,https:/www-statista-com.proxy.library.nyu.edu/statistics/1029548/china-number-of-students-returning-from-abroad/.128.Rolf D.Schmid and Xin Xiong,“Biotech in China 2021,at the beginning of the 14th five-year period(“145”),”Applied Microbiology and Biotechnology,vol.105(2021):29713985,https:/ Buckingham,“Will US lose biotech industry to China?”Medium,July 17,2023,accessed May 5,2024,at https:/ 25 countries of origin of U.S.doctorate recipients on temporary visas,by doctorate field:2020,”Survey of Earned Doctorates,2020,National Science Foundation,https:/ncses.nsf.gov/pubs/nsf22300/report/temporary-visa-holder-plans.132.Remco Zwetsloot et al.,“China is Fast Outpacing U.S.STEM PhD Growth,”Center for Security and Emerging Technology(CSET)Data Brief,August 2021,https:/cset.georgetown.edu/publication/china-is-fast-outpacing-u-s-stem-phd-growth/.133.Ibid.INFORMATION TECHNOLOGY&INNOVATION FOUNDATION|AUGUST 2024 PAGE 44 134.Berengere Macabeo et al.,“Access to innovative drugs and the National Reimburesement Drug List in China:Changing dynamics and future trends in pricing and reimbursement,”Journal of Market Access and Health Policy,vol.11,no.1(2023):https:/www.ncbi.nlm.nih.gov/pmc/articles/PMC10266112/.135.Atkinson,“The Impact of Chinas Policies on Global Biopharmaceutical Industry Innovation.”136.Chia-Feng Lu and Dawn(Dan)Zhang,“China on the move:Lesson from Chinas National negotiation of drug prices in 2022,”GT Greenberg Traurig,February 27,2023,accessed May 5,2024,https:/ Impact of Chinas Policies on Global Biopharmaceutical Industry Innovation.”138.Zhang et al.,“Technology Entrepreneurship,”Demystifying Chinas Innovation Machine:Chaotic Order.139.Stephen Ezell,“Ensuring U.S.Biopharmaceutical Competitiveness”(ITIF,July 2020),https:/itif.org/publications/2020/07/16/ensuring-us-biopharmaceutical-competitiveness/.140.Kate Ho and Ariel Pakes,“Evaluating Pharmaceutical Policy Options,”NBER Working Paper Series,June 2024,https:/www.nber.org/system/files/working_papers/w32606/w32606.pdf.141.“Exact Sciences(EXAS)Q4 2023 Earnings Call Transcript,”February 21,2024,The Motley Fool,accessed July 18,2024,https:/ Ezell,“Seizing the Transformative Opportunity of Multi-cancer Early Detection”(ITIF,April 2021),https:/itif.org/publications/2021/04/19/seizing-transformative-opportunity-multi-cancer-early-detection/.142.“S.2085 Medicare Multi-Cancer Early Detection Screening Coverage Act,”Introduced June 21,2023,Congress,https:/www.congress.gov/bill/118th-congress/senate-bill/2085.143.Stephen Ezell,“Ensuring U.S.Biopharmaceutical Competitiveness”(ITIF,July 2020),https:/www2.itif.org/2020-biopharma-competitiveness.pdf.144.Vadim J.Gurvich and Ajaz S.Hussain,“In and Beyond COVID-19:US Academic Pharmaceutical Science and Engineering Community Must Engage to Meet Critical National Needs,”AAPS PharmSciTech(2020),vol.20,no.5:153,https:/www.ncbi.nlm.nih.gov/pmc/articles/PMC7245992/.145.Robert D.Atkinson et al.,“A Techno-Economic Agenda for the Next Administration”(ITIF,June 2024),https:/itif.org/publications/2024/06/10/a-techno-economic-agenda-for-the-next-administration/.146.H.R.7085 BIOSECURE Act.Congress.gov.Accessed May 25,2024,https:/www.congress.gov/bill/118th-congress/house-bill/7085 147.Zhang et al.,“Technology Entrepreneurship,”Demystifying Chinas Innovation Machine:Chaotic Order.148.Ibid.
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InBody is pleased to announce the release of our second annual report.Since our establishment in 1996,InBody has remained firm in our commitment to enhancing peoples health over the course of 28 years.Throughout our extensive journey,we have meticulously gathered body composition data from diverse regions across the globe.The 2024 InBody Report presents comprehensive insights into peoples health and lifestyles,drawing upon the wealth of worldwide body composition data accumulated over the years.Since the publication of the 2023 InBody Report last year,InBodys body composition data has obtained global attention.Fitness trainers have broadened their coaching perspectives through InBodys body composition data,while academics have utilized it as a valuable tool for evidence in medical research and development.InBodys expansive data collection reflects the varied climates,environments,and cultures of the regions we live in,providing guidance on how and in what direction we should move towards creating a healthier future.As of August 2023,InBodys worldwide body composition data has reached 100 million records.The 2024 InBody Report presents detailed insights into body compositions from an even more diverse array of countries and individuals residing in distinct cultures and lifestyles.InBodys body composition data has now become more diversified and in-depth.We now find ourselves in an era where a focus on change is important.The InBody Report will persist in its role as a provider of global body composition trends,empowering individuals to make informed decisions for a healthier future.*The data used in this report were used solely for statistical purposes,providing only personal information that was agreed upon.Information that can identify individuals was not included in the content.InBody ReportIntroductionContentsINTRO05 The 2024 InBody Report:Methods for Data Processing 07 What You See Is Not What It Seems.The Limitations of Body Mass Index(BMI)09 A List of Body Composition TerminologiesMAIN.GlobalBodyCompositionTrendsbyCountry/Sex13 Country Rankings for Muscle Mass,Body Fat Percentage 15 Muscle Mass by Country by Protein Intake16 How do the U.S.and Europe Compare in terms of Muscle Mass?17 North America vs.South America,the Continents with Higher Body Fat Percentages19 Asian Countries Emphasis on Body Fat Percentage over Muscle Mass.NationalBodyCompositionTrendsbyAge/Sex21 Muscle Mass is the Secret to Youth?Countries With a Late Onset of Muscle Loss 23 Changes in the Body Fat Percentage of Women by Country25 Countries where BMI is misunderstood27 Thin Outside,Fat Inside:Females in Their 20s with High Body Fat Percentage28 Body Composition and Life Expectancy in Older Adults.BodyCompositionasaMedicalMarker29 Effects of Aging on Swelling:Examining the Causes of Edema through ECW Ratio31 Rapidly Declining Health in Countries Observed through the Lens of Cellular Health33 Read More Characteristics of Patients with Lymphedema based on Korean Data34 Diabetes Prevalence and Body Fat by Country35 Countries with the Highest Risk of Sarcopenia Based on SMI by CountryOUTRO39 Future Healthcare Trend for 2024:Cellular HealthInBody Report Body Composition Index of 17 Countries45 ReferencesThe contents of this report were prepared based on InBody measurement data accumulated from around the world,and they cover body composition trends in various countries,gender,and age groups.We would like to help all readers around the world who read this report to check and compare where their body composition is currently positioned,and lead a healthy life through more systematic body composition management.01INTROU.K.GermanyNetherlandsKoreaChinaAustraliaJapan,Thailand,Saudi Arabia,Malaysia,India,South Africa,Data on body composition from individuals worldwide,measured using InBody devices,is currently being accumulated in real-time in the cloud.On August 4,2023,the total number of data points surpassed 100 million,reaching 109,480,844 by November 2023,and ongoing data collection.For the 2024 InBody report,we analyzed 5 years worth of data collected worldwide from 2018 to 2022.To provide the most generalized information,statistical processing(based on Mahalanobis distance)was conducted to address input and measurement errors,and other factors.The report is based on data from 17 countries,including South Korea,Japan,China,the U.S.,the United Kingdom(UK),and Germany,and focuses on adults aged over 20 years who had taken InBody tests and showed high levels of interest in their health.The 2024 InBody Report:Methods for Data Processing*Thedatausedinthisreportwereusedsolelyforstatisticalpurposes,toprovideinformation,limitedtothedataforwhichpersonalinformationwasagreedupon,andnoinformationthatcanidentifyindividualsisincludedinthedata.05INTROMAINOUTROU.S.MexicoArgentinaAustraliaJapanCanada,Chile,KoreaMalaysiaMexicoNetherlandsSaudi ArabiaSouth AfricaThailandU.K.U.S.2,083,92817,68364,93453,4762,60361,78411,72181,730989,1513,488,43725,708108,85867,1052,71383,09113,23799,5491,435,4205,572,36543,391173,792120,581 5,316144,87524,958181,2792,424,571*DatafromChinaisthedataafter2019.*Weselectedthe17countriesbasedontheamountofaccumulatedbodycompositiondatacollectedbyInBodyProfessionalBCAdevicesineachcountry.ArgentinaAustraliaCanadaChileChinaGermanyIndiaJapanMale1,169140,09947,7683,06087,288109,161195,744133,725Female1,554256,04450,4166,570114,097133,605133,898189,541Total2,723396,14398,1849,630201,385242,766329,642323,2662024 InBody Report06 What You See Is Not What It Seems.The Limitations of Body Mass Index(BMI)BMI(Body Mass Index)is a metric used to assess obesity levels based on height and weight,providing a convenient way to roughly gauge overall health.However,in reality,individuals with low BMI values may have high body fat percentages,whereas those with high BMI values may have low body fat percentages.Therefore,caution is advised when interpreting BMI as a measure of overweight and obesity,as individuals with the same BMI may have different body compositions.BMI measurement considers individuals with the same height and weight as equals,failing to distinguish between those with high or low muscle mass resulting in higher or lower weight,respectively.A BMI value within the normal range does not necessarily correspond to a standard body fat percentage,and actual body fat percentage can be unrelated to BMI values.07INTROMAINOUTROOwing to varying health thresholds among individuals,relying solely on BMI for health status assessment is of limited value.Focusing solely on weight loss to reduce BMI can yield negative results.For instance,solely adjusting diet without incorporating exercise may lead to muscle loss and an increase in body fat percentage.This is a classic limitation of using BMI as a health status metric.To accurately understand current health status,precise measurement of body composition is crucial.By measuring exact muscle mass and body fat percentage,individuals can gain a clear understanding of their current state and chart a course for the future.The 2024 InBody report focuses on muscle mass and body fat percentage to understand global body composition trends.The report reveals trends by country,age,and sex based on muscle mass and body fat percentage,as well as how body composition can be used as medical information and predicts the 2024 health trends.2024 InBody Report08A List of Body Composition TerminologiesThe human body is composed of various components such as water,fat,protein,and minerals,collectively referred to as the body composition.In this report,we use several terms related to body composition.To help readers understand these terms more easily,we have organized them into related categories.1.Body Mass Index(BMI)BMI is a measure of body weight relative to height.It is calculated by dividing an individuals weight in kilograms by the square of their height in meters(kg/m2).The BMI is commonly used in nutritional science and sports medicine to assess the degree of apparent obesity.2.Percentage Body Fat(PBF)PBF(%)=(Body Fat Mass(kg)/Weight(kg)100PBF measures the amount of fat mass by dividing the body fat mass by weight and multiplying it by 100.Although BMI is determined by weight and height,it cannot accurately diagnose obesity because it fails to reflect changes in both muscle and body fat mass.Therefore,bodybuilders with high muscle mass and low body fat may be diagnosed with obesity.However,PBF is an index that is often used to determine whether someone is overweight as it indicates the amount of body fat present.Owing to different body structures,PBF standards are different for men and women,with the standard range for men being 1020%and for women being 1828%.3.Fat-Free Mass(FFM)FFM(kg)=Weight(kg)Body Fat Mass(kg)FFM is also known as lean mass.Despite weighing the same weight,some individuals appear thinner whereas others appear heavier.Body components can be divided into two categories:fat and non-fat.Fat stored in the body is referred to as body fat,whereas the weight remaining after subtracting body fat is known as lean mass.Lean mass consists of elements that comprise the human body,such as the muscles,bones,organs,brain,and water,excluding body fat.Muscle is the most important component of lean mass,as it contributes to a higher basal metabolic rate.Therefore,a higher proportion of lean mass in the body can be beneficial for metabolism and overall health.4.Body Fat Mass(BFM)BFM(kg)=Weight(kg)Fat Free Mass(kg)As mentioned earlier,body weight is the sum of BFM and FFM.A high amount of body fat increases the risk of cardiovascular diseases such as diabetes,high blood pressure,and hyperlipidemia.5.Skeletal Muscle Mass(SMM)Three types of muscles constitute the body:myocardium,smooth muscle,and skeletal muscle.Myocardium refers to the muscles of the heart,and smooth muscle refers to the muscles present in organs.Myocardium and smooth muscle are involuntary muscles that cannot be controlled at will,whereas skeletal muscle is attached to the bones or tendons and contracts voluntarily to create movement.When we talk about building muscle with exercise,we are usually referring to building skeletal muscle.6.Skeletal Muscle mass Index(SMI)SMI(kg/)=Appendicular Skeletal Muscle Mass(kg)/Height()SMI is calculated by dividing the muscle mass of the limbs excluding the trunk by the square of the height()and is an important diagnostic index.In 2016,the World Health Organization classified sarcopenia as a disease,making SMI a key tool in diagnosing the condition.Sarcopenia refers to the gradual loss of muscle mass and strength that occurs with aging.According to the diagnostic criteria of the Asian Working Group on Sarcopenia 2019,SMI 7.0 kg/m for men or 0.400 generally considered high.8.Whole Body Phase AngleThe phase angle shows the resistance of the cell membrane in degrees,and the higher the structural stability of the cell(cell membrane integrity),the larger the value.It is used as an indicator of the nutritional status of cells,severity assessment of chronic diseases,and life prognosis,as the value is large when the cell is healthy and approaches zero as the cell membrane condition deteriorates.Typically,the phase angle is the right half of the body in the 50 kHz frequency band,which is called the whole body phase angle.11.National Body Composition Trends by Age/SexThe previous chapter discussed the differential distribution of body compositions within each country.But what are the differences in body composition by age and sex within a country?In this chapter,we will take a closer look at body composition trends by age and sex.Body Composition as a Medical MarkerThe flow of body composition can be a very important indicator for diagnosing disease,tracking whether you are getting better or worse,and prognostication after surgery or recovery.In this chapter,well look at body composition by country,with a focus on extracellular water as a medical marker.Global Body Composition Trends by Country/Sex Within a country,people with different body compositions coexist,and globally,countries exhibit different body compositions owing to racial and cultural differences.In this chapter,we will take a closer look at muscle mass and body fat percentage in 17 countries based on InBody big data.02MAINBefore diving into the InBody report,let us look at the average muscle mass and body fat percentage data for each country,as measured by InBody,in the graph below.The graph also includes South Africa,Chile,Saudi Arabia,Argentina,and Thailand,which were not covered in the 2023 InBody report.Muscle Mass by CountryThe SMI is a convenient and accurate metric for objectively measuring muscle mass,which naturally increases with height.A higher SMI value indicates greater muscle mass.1 The graph below in Figure 1 shows that the top 7 of 17 countries with high SMI values,regardless of sex,include the U.S.,Australia,South Africa,Germany,the Netherlands,Canada,and the UK.The countries with the lowest SMI values(i.e.,lower muscle mass)include Asian countries,with Japan having the lowest SMI values for both men and women.However,in Asian countries,the SMI values do not vary significantly and are almost identical.Overall,Western countries have higher muscle mass,whereas Asian countries have lower muscle mass.Did the country rankings meet your expectations?Country Rankings for Muscle Mass,Body Fat Percentage Figure 1:World ranking of the average Skeletal Muscle mass Index(SMI)of male and femaleSMI#1:UnitedStatesSMI#17:JapanSMI#1:AustrailiaSMI#17:JapanSkeletalMusclemassIndex(SMI)isgenerallyproportionaltomusclemass.13INTROMAINOUTROBody Fat Percentage by CountryBody fat percentage is a value that indicates the proportion of total body weight that is fat,expressed as a percentage.Body fat distribution varies in both non-obese and obese adults.Major environmental factors that influence body fat distribution include alcohol consumption,smoking,and the timing of childhood obesity onset,although strong genetic factors also influence fat gain and loss.Because upper body visceral fat distribution in obesity is strongly associated with metabolic complications,weight loss through diet/exercise is important.2 However,body fat and adipose tissue have beneficial effects in promoting or protecting current and future bodily functions and play an important role in sexual function.In addition,metabolism,bone health,immune function,and energy balance are also related to body fat and fat distribution.3 In other words,having very low body fat is also harmful to health.Therefore,studying the body fat percentage of each country is a valuable way to assess health status.The average body fat percentage for each country in the 2024 InBody report is shown below in Figure 2.Japan,which has the lowest muscle mass,also exhibits a low body fat percentage,which seems to be representative of the general Asian population.Chile,India,and Mexico have the highest levels of body fat,while North American and European countries with the highest SMI values generally maintain lower levels of body fat percentage due to their greater muscle mass.However,American women have high levels of body fat percentage despite having more muscle mass,a topic we shall discuss later.Figure 2:World ranking of the average Percentage Body Fat(PBF)of male and femalePBF#1:ChilePBF#17:JapanPBF#1:ChilePBF#17:ChinaPercentBodyFat(PBF)isgenerallyproportionaltobodyfat.Global Body Composition Trends by Country/Gender14Muscle Mass by Country by Protein IntakeFigure 3:Comparison of daily protein intake and Average SMI values by country.How much protein do you normally consume?Protein is often considered the magic substance in the modern world that builds muscle,but,in reality,muscle mass is influenced by many factors other than protein.Therefore,it is not easy to directly correlate protein intake with muscle mass,as muscle mass is typically determined by many variables other than protein intake,including exercise,genetics,age,sex,and personal health status.Nevertheless,adequate intake of protein,the main building block of muscle,is important for maintaining optimal health during normal growth and aging.4 The 2024 InBody report compares protein intake and muscle mass across countries,excluding exercise levels,genetics,and personal health conditions.Figure 3 shows that the U.S.has the highest daily protein intake,averaging over 110 grams per day,and the highest muscle mass for both men and women.Similar to the comparison of SMI values in the previous chapter,countries in North America,Europe,and Oceania continents have high SMI values,indicating that individuals in these countries consume 100 grams of protein per day.Although implies that high protein intake can lead to more muscle mass,there is another part of the graph that is interesting to look at.Despite having a relatively low protein intake compared to other countries,South Africa shows a high SMI value,and Asian countries,which have moderate protein intake,have the lowest muscle mass.From these facts,it appears that,among the many factors that determine muscle mass,once protein intake exceeds a certain level,muscle mass varies depending on genetics,personal health,and cultural practice.What do you do besides eating protein to increase muscle mass?CountrieswithhighproteinintaketendtohavehigherSMIvalues.15INTROMAINOUTROFigure 4:Comparison of SMI and PBF between the United States of America(U.S.)and Europe in maleFigure 5:Comparison of SMI and PBF between the United States of America(U.S.)and Europe in femaleHow do the U.S.and Europe Compare in terms of Muscle Mass?Although the U.S.and Europe are geographically separated,they share the commonality of having populations with diverse cultural and racial backgrounds.Both regions are internationally recognized for their leading advancements in science,technology,and economics,which have led to the concept of the West as a whole.However,the two continents differ in several indicators,including diet,lifestyle,exercise culture,and health systems,and this is reflected in small differences in body composition(Figure 4).In particular,many studies have shown that the health of middle-aged Americans,and health-related indicators such as smoking and obesity,are much worse than in Western European countries.5Men in the U.S.and Europe have relatively large differences in SMI and body fat percentage.Regarding SMI,men in the U.S.have an SMI of approximately 9.1,whereas that for men in the three European countries,the UK,Germany,and the Netherlands,ranges between 8.7 and 8.8.The U.S.has a relatively low body fat percentage owing to high muscle mass,but it still tends to have a higher level of body fat compared to Europe.Women exhibit even more significant differences in body fat percentage(see Fig.5).Women in the U.S.have an SMI of 7.2,slightly ahead of counterparts in the three European countries by a margin of 0.1 to 0.2.However,they possess a body fat percentage approximately 3%higher than that of European women.The observed variation in body fat percentage between these two continents,both characterized by high protein intake,is likely attributed to differences in food and exercise culture.What factors do you believe contribute to these distinctions in body fat percentage?Which Countries Have More Muscle Mass?Americanmenhavea1.5%higherbodyfatratethantheirEuropeancounterparts.AustralianmenhaveasimilarbodycompositiontoAmericanmen.ThissuggeststhatAmericanwomen,assumingequivalentweight,havelessmusclemassthantheirEuropeancounterparts.AustralianwomenhaveasimilarbodycompositiontoEuropeanwomen.Global Body Composition Trends by Country/Gender16Next,let us look at body composition trends within the Americas.We investigated five countries in the Americas in the 2024 InBody report:the U.S.,Canada,and Mexico in the Northern Hemisphere,and Argentina and Chile in the Southern Hemisphere;these countries have different food and exercise cultures.Because the body composition of individuals in Mexico is more similar to that of South American countries than of North America,we used data from the U.S.,Canada,Argentina,and Chile to compare North and South American data(Fig.6).In the 2023 InBody report,we examined seasonal changes in body fat percentage in South Korea and Australia.In the 2024 InBody report,we took a similar look at seasonal changes in body fat percentage in North and South America.People in each country have a pattern of lower body fat percentage in the summer and higher body fat percentage in the winter,which can be attributed to increased outdoor activity and sunshine in the summer that results in increased activity and calorie expenditure,and lower body fat percentage.As in the case of South Korea and Australia,we saw similar trends,with lower body fat percentages in their respective countries during the summer months and higher body fat percentages during the winter months.Notably,these patterns were more pronounced in men than in women.North America vs.South America,the Continents with Higher Body Fat PercentagesFigure 6:Seasonal changes in Percentage Body Fat(PBF)in North and South American maleTherearesubtlechangesinbodyfatpercentagewiththeseasons.Inthesummer,bodyfattendstobelower,andinthewinter,bodyfattendstobehigher.17INTROMAINOUTROIn addition to these patterns of seasonal variation in body fat percentage,the North and South American continents show large differences in both muscle mass and body fat percentage.The U.S.and Canada have relatively high muscle mass,and their body fat percentage is intermediate among the 17 countries.Chile,however,has a lower muscle mass and a higher body fat percentage composition.Mexican men have a body composition distribution more similar to that of South America than of North American(Fig.7).Australian men have a body composition similar to that of American men)American women,who have about 3%more body fat percentage than Europeans,have similar body fat percentages as women in South American countries(Fig.8).American women have relatively higher muscle mass than women in South American countries.Canadas body composition tended to be more similar to that of continental Europe than to that of the U.S.(Australian women,unlike men,tended to be more similar to that of continental Europe.)Argentina has the lowest muscle mass for both men and women among the countries in the Americas tracked in the 2024 InBody report,which warrants further research and consideration.The differences between North America and South America appear to be greater than the differences between North America and Europe,suggesting that body composition can be influenced by the dietary and exercise culture of each country,even if they are geographically close.Figure 7:Comparison of SMI and PBF between North and South American countries in maleFigure 8:Comparison of SMI and PBF between North and South American countries in femaleNorthAmericanmentendtohavemoremusclemassthanSouthAmericanmen.Despitetheirhighmusclemass,AmericanwomenhaveasmuchbodyfatasLatinAmericanwomen.Global Body Composition Trends by Country/Gender18Let us also look at body composition trends within the Asian continent.We considered six countries in Asia:South Korea,Japan,China,Malaysia,Thailand,and India.Except for India,the Asian countries have one thing in common:their BMIs are the lowest among the 17 countries.These countries can be categorized by climate and culture:Korea,Japan,and China in East Asia;Malaysia and Thailand in Southeast Asia;and India in South Asia.Asian countries have the characteristics of having the lowest SMI values for muscle mass for both men and women.However,body fat percentages show distinct country-specific characteristics.Asian Countries Emphasis on Body Fat Percentage over Muscle Mass19INTROMAINOUTROJapan has the lowest muscle mass and body fat percentage.Regarding body composition of countries other than Japan,Figure 9 shows that,overall,men in East Asian countries have higher muscle mass and lower body fat than Southeast Asian countries.Thailand,however,is unique in that it has a composition closer to East Asian countries for both muscle mass and body fat percentage.Figure 10 shows that continental differences in muscle mass are not as pronounced for Asian women as they are for men,although Indian women are uniquely high in both muscle mass and body fat percentage.Of course,India has a smaller user base than other countries;however,even considering that,it is still an unusual result.Chinese women have the lowest body fat percentage of all 17 countries.Most uniquely,the body composition of Thai women is closer to that of East Asia than of Southeast Asia.This again shows that although countries may be geographically close,their dietary and exercise cultures can influence their body compositionFigure 9:Comparison of SMI and PBF in Asian countries in maleFigure 10:Comparison of SMI and PBF in Asian countries in femaleSoutheastAsianmentendtoexhibitahigherbodyfatpercentageincomparisontotheirEastAsiancounterparts.Global Body Composition Trends by Country/Gender20 Muscle Mass is the Secret to Youth?Countries With a Late Onset of Muscle Loss One of the most affected elements of aging is the muscle.After 30 years of age,the muscle mass declines by about 3-8%per decade,and the rate of decline accelerates after age 60 years.Furthermore,the loss of muscle mass is directly linked to an increase in body fat,which leads to changes in body composition and is associated with an increase in insulin resistance in older adults.6 The 2023 InBody report examined differences in the timing of muscle mass loss in men in the East and West,which showed that because male hormonal changes decline around the age of 35-44 years7,muscle mass also declines in a similar pattern,and that the timing varies by country.This was of interest to many because muscle mass loss is often seen as a sign of the onset of aging.In the 2024 InBody report,we studied these differences in Germany and Malaysia along with the U.S.and South Korea.American men with the highest average muscle mass started to lose muscle mass at age 41 years,whereas German men with lower muscle mass started to lose muscle mass a little later at age 44 years(Fig.11).Figure 11:Comparison of the onset of muscle loss in male in the U.S.and Germany21INTROMAINOUTROIn South Korea,which has a higher average muscle mass than Malaysia,the age of onset of muscle loss is 33 years,which is earlier than the age of 39 years for Malaysian men(Fig.12).Higher muscle mass does not necessarily lead to later muscle loss.However,countries with high muscle mass have higher levels of muscle mass at the same age,despite muscle loss.Further research is needed to determine whether more or less muscle mass contributes to aging.In general,it is important to build muscle mass during youth to stay healthy longer and delay the onset of muscle loss.Figure 12:Comparison of the onset of muscle loss in male in Korea and Malaysia.National Body Composition Trends by Age/Gender22Changes in the Body Fat Percentage of Women by CountryThe phenomenon of body fat percentage changing with age is closely related to several physiological factors.In particular,body fat percentage in women tends to increase with age,which provides important information to improve our understanding of womens health and future disease risk.The 2024 InBody report shows the age-specific body fat percentage of women in 17 countries.The increase in body fat percentage with age is observed in all countries;moreover,the timing of the increase reveals that women show an upward trend in body fat percentage through their mid-40s,followed by a sharp increase in body fat percentage as they enter their 50s.In other words,regardless of the country,there is a common pattern of a sharp increase in body fat percentage in the 40s and 50s as women enter menopause,followed by a slight decrease in body fat percentage in the mid-50s,followed by a sharp increase as they enter their 60s.The timing of changes in body fat percentage varies in different countries.Figure 13 shows that in general,Asian women appear to have a later increase in body fat percentage than women in Europe and the Americas.In particular,Asian womens body fat percentage is characterized by a minimal increase in body fat percentage in their 20s and a tendency to decrease or maintain body fat percentage.In Japan,an increase in body fat percentage is observed from the 20s to the 30s,although this increase is lower than the body fat percentage observed in the 20s in other countries;hence,this is not concerning.Inwomen,adiscernibleupwardtrendinbodyfatpercentageofteninitiatesintheirmid-40s.Nevertheless,outcomesduringthe20sdifferacrosscountries.23INTROMAINOUTROFigure 14:Changes in PBF with age of female in U.S.,UK,and GermanyFigure 14 shows similar but different patterns for the UK and Germany,with UK women maintaining their body fat percentage in their 20s,whereas German women show an increase with age.However,the body fat percentage of women in their 30s in Germany is lower than the body fat percentage of women in their 20s in the UK,which is similar to the Japanese example mentioned earlier.Figure 13:Changes in PBF with age of female in Korea,Thailand,and Japan.National Body Composition Trends by Age/Gender24Countries where BMI is misunderstoodAs shown in Figure 15,men in 11 of the 17 countries are obese according to BMI but not obese.For example,American men have high BMI but not high body fat percentage,meaning that people who are classified as obese by BMI may not be obese if they have a lot of muscle.The countries at the bottom of the list relative to the U.S.have a high body fat percentage despite having a lower BMI than the U.S.As discussed in the introduction,BMI alone is not a true indicator of body composition,as many individuals have a different body composition than what is visible.Therefore,considering BMI alone may imply a high body fat percentage,whereas the reverse may be true.Let us examine which countries have a lower body fat percentage than they appear to.Figure 15:Countries that have a lower percentage body fat(PBF)than indicated by body mass index(BMI)in male25INTROMAINOUTROFigure 16:Countries that have a lower percentage body fat(PBF)than indicated by body mass index(BMI)in femaleConversely,Malaysian women have low BMI but not body fat percentage,as shown in Figure 16.Women are obese according to BMI in Germany and the Netherlands but not by body fat percentage.This is because they have high muscle mass that results in high BMI.If women were to use their BMI to guide their healthcare,they would be more likely to go down the path of obesity.An understanding of this concept encourages the habit of checking body composition regularly to determine the gain or loss of weight,muscle,or body fat percentage.Ultimately,it is the body composition that matters not weight.Womentendtohavehigheroverallbodyfatpercentages,requiringguidanceinexerciseanddietformuscledevelopment.National Body Composition Trends by Age/Gender26Not monitoring body composition and relying only on BMI at younger ages may delude one into thinking they are healthy,which is dangerously misleading.Individuals with lean obesity have been shown to have high levels of metabolic dysregulation,which is associated with a significantly higher risk of developing metabolic syndrome,cardiometabolic dysfunction,and higher mortality.8 Therefore,it is important to use muscle mass and body fat percentage instead of weight as health indicators.Figure 18:Comparison of SMI and PBF of Korean and Australian in female in 20sFigure 17 shows that the following Asian countries have the highest rates of female lean obesity:South Korea,Thailand,Malaysia,Japan,and China.Women in these five countries have lower BMIs than women in Western countries,with many within the standard BMI range;however,a large proportion lacks muscle mass and has a high body fat percentage.This appears to depend on whether the diet is viewed as weight or body composition.Figure 18 presents the BMI,SMI,and PBF of Korean women in their 20s compared to Australian women in their 20s.Because Korean women have a lower BMI,they naturally have a higher percentage of muscle mass below the cut-off for sarcopenia,even at a similar body fat percentage to Australian women.Thin Outside,Fat Inside:Females in Their 20s with High Body Fat PercentageLean obesity describes a condition in which a person is not outwardly obese but has a high percentage of body fat.8 In simple terms,it indicates a person of normal weight with a high percentage of body fat.This is usually seen when a person lacks muscle mass,even if their body fat mass is in the normal range.The phenomenon of lean obesity is more prevalent in women than in men and is more prevalent in Asia than in the Americas and Europe.Interestingly,a pattern of declining rate of lean obesity is observed as individuals move from their 20s to their 40s,which suggests that lean obesity is not resolved by a decrease in body fat percentage,but rather a shift out of the category of lean obesity and into general obesity due to weight gain.Figure 17:World ranking of lean obesity percentage in female in 20sInAsia,manywomenintheir20smaynotbeclassifiedasobesebyBMI,butrather,theyareconsideredobeseduetotheirhighbodyfatpercentage.AlowBMIdoesntalwaysindicategoodhealth;itcanalsosuggestadeficiencyinmusclemass,asdemonstratedbyKoreanwomenintheir20s27INTROMAINOUTROFigure 19:Comparison of Expected life and percentage of healthy older adults in male and femaleBody Composition and Life Expectancy in Older AdultsThe ideal body composition is a balance of high muscle mass with a certain level of body fat percentage.This remains true as we age,with older adults lacking muscle at risk of diseases such as sarcopenia,and older adults with high body fat percentages at risk for diseases such as diabetes and metabolic syndrome.However,a change in body composition with age is well established(even without a change in BMI).Body fat mass increases and muscle mass decreases.This is thought to be partly due to a slowing of long-term metabolic rate as resting metabolic rate decreases with age,which may contribute to changes in body fat percentage and muscle mass.9 Therefore,maintaining a body composition of high muscle mass and low body fat percentage at an appropriate body weight is critical to healthy older age.In general,for individuals aged over 50 years,an increase in BMI is associated with a significant decrease in chronic disease-free life expectancy.10 This is because it is difficult to gain muscle mass at that age;hence,an increase in BMI means an increase in body fat.To determine whether life expectancy was associated with healthy older age,we examined the relationship between the percentage of older adults with body fat percentage in the standard range and muscle mass above the sarcopenia cut-off in each country and life expectancy and found that for both men and women,the higher the percentage,the higher the life expectancy(Fig.19).However,improvements in healthcare and nutrition have led to longer life expectancies and a rapidly aging population has led to an increase in the prevalence of chronic diseases.11 Because a high life expectancy does not guarantee a healthy life,it is important to prepare for a healthy life through proper body composition management.Thisgraphisbasedonthepercentageofolderadultsover50withastandardbodyfatpercentageandsufficientmusclemass.National Body Composition Trends by Age/Gender28Our bodies seem to swell more often with age,and even when we are not aging,swelling is observed when we are unhealthy.Swelling,also known as edema,is one of the most intuitive indicators of our general health status.What is edema,and why and how does it occur?As more than 60%of our bodies comprise water,the water balance is the first to be affected by deteriorating health.Intracellular water(ICW)is usually the water in the muscles,whereas Extracellular water(ECW)is the water in the body that causes swelling(Fig.20).In general,healthy people maintain a constant body-water ratio;however,this is disrupted by disease,toxins,and inflammation,or poor nutrition,making body water a critical metric in the medical field.Understanding extracellular and intracellular waterNormal ECW ratio(left)and edema with an ECW ratio of 0.390(right)IntracellularWater(ICW)ExtracellularWater(ECW)NormalEdemaNutritionally balancedcellular conditionsMalnourishedcellular conditions Effects of Aging on Swelling:Examining the Causes of Edema through ECW RatioThe ECW ratio is calculated as ECW/Total body water.The normal range is 0.3600.390,with 0.3900.400 indicating mild edema and 0.400 indicating severe edema,which may present as fatigue,obesity,nutritional deficiencies,hypokalemic syndrome,or kidney abnormalities.When the ECW ratio exceeds a certain range,increased attention is necessary to monitor health.It is also important to distinguish between ICW and ECW water to properly determine the health status.InBody examined trends in the average ECW ratio for men and women in 17 countries(Fig.21).In general,women have higher average ECW ratios than men,and both sexes show an increase in the ECW ratio with age.Figure 20:Edema and Cellular health through the lens of Intracellular and Extracellular water29INTROMAINOUTROThere are several reasons for the difference in ECW ratio between men and women,but at its most basic,differences in muscle mass can lead to differences in ECW ratio.Women,who have relatively lower muscle mass compared to men,naturally have higher ECW ratios.Since men have more muscle mass than women,they have lower ECW ratios;however,with increasing age,the rise in the ECW ratio is more pronounced than that in women.One possible reason for this is that muscle mass loss is much greater in men than in women.ECW retention can increase with age due to continued muscle loss,poor nutrition,and medical conditions.When middle-aged men and women say they feel swollen it is often due to the increased ECW ratio.Additionally,inflammation,muscle loss,and other conditions can also contribute to an increase in the ECW ratio.Tracking body hydration is important for managing several conditions,including kidney disease,lymphedema,diabetes,and cancer.First,patients with kidney disease get edema because their weakened kidney function does not support the removal of enough water,as a result of which they accumulate fluid in their bodies and need to regularly undergo dialysis to get rid of the excess water through dialysis.Second,if the overhydration is more severe than expected,or if dialysis does not remove enough water and the patient is always overhydrated,it can lead to cardiovascular problems such as high blood pressure,edema,and an enlarged heart.This fluid balance is called the“dry weight”setting,which is an individuals weight at their peak energy level with normal blood pressure and no edema.In hemodialysis,an incorrect dry weight setting can lead to problems such as hypotension and shock.Lymphedema,a complication following breast cancer surgery,is another case where fluid management is critical.Continuous changes in ECW in the operated arm(ipsilateral arm)and the unoperated arm(contralateral arm)can be used to detect abnormalities,and the difference between the two can be compared to that of a normal person to determine the extent of the disease.The bodys water ratio changes in cancer or inflammation.In diabetes,the blood flow is impaired,causing long-term problems with kidney function.By monitoring changes in body water,disease progression can be monitored.Figure 21:Changes in the average ECW ratio in male and female by ageWithaging,theECWRatioincreases.WomengenerallyhaveahigherECWRatiothanmen,buttheslopeoftheincreaseissteeperinmen.Body Composition Information as a Medical Indicator 30We shall explore this topic with Phase Angle.Phase angle is an indicator of how strong the cell membrane is,or of cell health.Phase angle is a measure of the structural integrity of cell membranes and their level of physiological function,helping to predict the health of cell membranes and the function of mitochondria to assess aging and chronic fatigue,immune status,and nutritional status in patients with cancer.Checking the phase angle marks the beginning of a comprehensive body balance and health assessment.While there is no clear-cut threshold for the phase angle,a sharp drop or significant fluctuations could indicate an underlying health condition.Therefore,regular measurements of the phase angle to monitor cellular health are advisable.Hundreds of millions of cells constitute the entire body.What better indicator of ones overall health than looking at the health of ones cells?We focused on the importance of cellular health and decided to study phase angle by country based on the fact that poor cellular health leads to poor overall body health.With age,the phase angle decreases;cells progressively lose water,and their shape and condition gradually deteriorate(Fig.22).Let us first examine the phase angles of women in the East and West.Rapidly Declining Health in Countries Observed through the Lens of Cellular HealthFirst,the largest decline in phase angle among women worldwide is in the U.S.From a phase angle of 5.8 in their 20s,it drops to 4.4 in their 70s.Whereas women in most countries have a phase angle difference of 0.8 to 1.0,women in the U.S.have a difference of 1.4.The phase angle in Chinese women increases from their 20s to their 30s,then begins to decline in their 40s,with a very steep decline from a phase angle of 4.8 in their 60s to a phase angle of 4.2 in their 70s(Fig.24).This is a slightly different pattern than most other countries,where the phase angle declines more gradually in women.Chinese women are advised to check their overall health through monitoring cellular health twice,once in their 40s and again in their 60s.Figure 23:Changes in phase angle and skeletal muscle mass(SMM)by age among female in the U.S.ThephaseangleforwomenintheUSandtheNetherlandsgraduallydecreases,startingintheir20s31INTROMAINOUTROWe analyzed changes in phase angle in conjunction with SMM to understand the correlation between muscle gains and losses and changes in phase angle.Similar patterns were observed across countries and sexes.Either phase angle and SMM start to decrease simultaneously,or phase angle decreases more rapidly to coincide with muscle loss.As Figure 24 shows,in Chinese women,both muscle and phase angle increase in their 20s,and then both metrics decrease in their 40s.Dutch women(Fig.25)and South Korean women(Fig.26)exhibit an increase in muscle and a slight decrease in the phase angle starting in their 20s,but the slope of the phase angle decline graph increases sharply with the decrease in muscle starting in their 40s(Fig.25).One notable difference was observed between women in the East and West.American and Dutch women have a decreasing phase angle starting in their 20s.Chinese and Korean women,on the other hand,see an increase in phase angle in their 20s and 30s,which starts to decline in their 40s.The phase angle in Western women continues to decrease,whereas that in Eastern women increases and then decreases.Figure 24:Changes in phase angle and skeletal muscle mass(SMM)by age among female in ChinaFigure 25:Changes in phase angle and skeletal muscle mass(SMM)by age among female in NetherlandsFigure 26:Changes in phase angle and skeletal muscle mass(SMM)by age among female in South KoreaThephaseangleforAsianwomeninChina(Fig.24)andKorea(Fig.26)increasesthroughouttheir30sbutdecreasesintheir40s.Body Composition Information as a Medical Indicator 32 Read More Characteristics of Patients with Lymphedema based on Korean DataBreast cancer is a condition that extends beyond surgery and treatment,marking the commencement of a journey to live with cancer.Breast cancer is linked to high recurrence rates and the risk of various complications.Notably,50%of patients who have undergone breast cancer surgery are diagnosed with lymphedema,an abnormal swelling of specific areas.More than 60%of these cases fall into the category of early-onset patients who develop lymphedema within 3 years after breast cancer surgery.Lymphedema arises from damage to the lymphatic system,responsible for moving lymphatic fluid from the bodys periphery to the center.A compromised lymphatic system prevents proper fluid drainage,leading to the accumulation of excess water and protein-laden sticky fluid between cells.This accumulation results in severe swelling of the arms or legs,resembling an elephants limbs in severe cases.InBody sought to gain a clearer understanding of the hydration levels of patients with lymphedema by comparing body composition data from patients with lymphedema to those without lymphedema.Lets examine the difference between the two arms of patients with lymphedema.The contrast between the operated and unoperated arms of these patients is striking.The operated arm exhibits a higher ECW content than the unoperated arm,indicating an imbalance of water between the two arms(Fig.27).Figure 27:Difference between the operated and unoperated arms of patients with lymphedemaFigure 28:Difference between the right and left arms of individuals without lymphedemaHowever,there is no difference in the ECW ratio between the two arms of an individual without lymphedema(Fig.28).Similarly,the body composition is generally harmoniously balanced unless affected by surgery or health problems.This shows the importance of the balance of our body composition.Theoperatedarm(surgicalsite)ofapatientwithlymphedemaexhibitsahigherECWratiothanthenon-operatedarm,resultinginanimbalancebetweenthetwoarms.(Fig.27)INTROMAINOUTRO33Diabetes Prevalence and Body Fat by CountryThisgraphindicatesaproportionalcorrelationbetweenbodyfatpercentageanddiabetesprevalence.Many people have diabetes,but did you know that there is a strong relationship between diabetes and body composition?Of the 17 countries covered in the 2024 InBody report,we compared body composition between Malaysia,the country with the highest prevalence of diabetes,and the Netherlands,12 the country with the lowest prevalence of diabetes,based on the 2021 global diabetes prevalence data published by the International Diabetes Federation.First,in Malaysia,the average PBF of men and women is on the higher side,30%.They typically have less muscle mass and more body fat mass.Let us study body composition in the Netherlands,a country with one of the lowest prevalence rates of diabetes.The average PBF of men and women in the Netherlands is relatively low,28%.This is the complete opposite of Malaysias body composition.Data on the global prevalence of diabetes such as in Malaysia and the Netherlands,correlates with body fat percentage,reinforcing various studies that have shown that higher body fat predisposes to diabetes.Figure 29:Comparison between diabetes prevalence and percentage body fat by country2024 InBody Report34Sarcopenia is characterized by a loss of muscle mass and decreased muscle function,manifesting in symptoms such as lower extremity weakness that slows walking and makes it difficult to rise from a seat.While muscle mass and strength naturally decline with age,sarcopenia represents an excessive loss of muscle mass and strength,even after accounting for age and sex,resulting in reduced physical function and increased health risks and mortality.Sarcopenia can be detected through handgrip strength,physical performance,and SMI measurement.SMI can be measured with InBody,and continental sarcopenia societies have published SMI criteria for determining sarcopenia.We examined countries with the highest percentage of individuals with sarcopenia based on the criteria set by the Asian and European sarcopenia societies.Firstly,the percentage of individuals with sarcopenia is higher among women than among men.The country with the highest rate of sarcopenia in men in the study is India,where 8.5%of Indian men have an SMI of 7.0.The country with the highest rate of sarcopenia in women is Thailand,with a rate of 25.8%.This represents more than a threefold difference in percentage.Next,let us explore the ranking of countries by sex.According to the SMI criteria specified by the Muscular Dystrophy Society for each continent,the countries with the highest proportion of women with sarcopenia are Thailand,Malaysia,Japan,China,South Korea,and India,in this order,with all of the top countries in Asia(Fig.30).Men also have higher rates of sarcopenia in Asian countries.China takes the fifth place,followed by India,Malaysia,Japan,and Thailand(Fig.31).In contrast,European countries such as Germany and the Netherlands have relatively low rates of sarcopenia.Although the causes of sarcopenia vary among individuals,it is usually attributed to poor protein intake and a lack of exercise.Asian countries with high rates of sarcopenia typically have lower protein intake than Western countries.Countries with the Highest Risk of Sarcopenia Based on SMI by CountryINTROMAINOUTRO35Figure 30:Ranking of countries with high rates of sarcopenia in female according to skeletal muscle mass index(SMI)valuesFigure 31:Ranking of countries with high rates of sarcopenia in male according to skeletal muscle mass index(SMI)values Thisgraphdepictsthepercentageofthepopulationidentifiedwithsarcopenia,applyingcontinent-specificcriteriaandutilizingaverageSkeletalMusclemassIndex(SMI)valuesforbothmenandwomenbycountry.2024 InBody Report36INTROMAINOUTRO37The availability of body composition analyzers has significantly altered the way people worldwide view health indicators.Prior to their widespread use,weight and BMI(Body Mass Index)were the primary measures used to assess health.Peoples awareness of body composition has increased,and body composition analyzers are becoming more accessible.The changes in our lifestyles require us to explore this field,which is now readily available.03OUTRODid you know that our bodies are made up of an average of about 30 trillion cells?Cells are the basic building blocks of our bodies,and throughout our entire life cycle,we live and die by their function.These tiny biological units are responsible for amazing things like converting nutrients into energy,creating new cells,and removing harmful substances.Cells store their genetic information in DNA,which they use to synthesize proteins and other biomolecules to maintain the function of tissues and organs.Our bodys health is highly dependent on the number and function of our cells,and their smooth operation is crucial to maintaining proper metabolism and overall physiological balance.There was a time when weight,BMI,and a superficial healthy look were the only measures of health.InBody has steadily taught the world the importance of balancing body compositionbody fat,muscle mass,and waterand people worldwide now choose body composition to assess their health.InBodys predicted healthcare trend for 2024 is cellular health.The basis of all body composition starts with the cells.When the cells are healthy,body composition is balanced,and when body composition is balanced,health can be discussed.Health is increasingly becoming a concern,and the healthcare industry advances at an incredible rate every year.As the pace of progress increases,we need to focus on the basics:strong muscles,moderate body fat to keep our bodies functioning,body hydration as a measure of health,and cellular health as the foundation of all these body components.It all starts with a healthy diet and exercise lifestyle.It is 2024!So,why not start with a solid eating and exercise plan for a healthy life?Future Healthcare Trend for 2024:Cellular HealthINTROMAINOUTRO39Based on insights derived from InBody big data,we have examine the body composition by country.The 2024 InBody Report includes average body composition index for men and women in 17 countries,which are provided in the appendix.AppendixInBody Report Body Composition Index of 17 CountriesAppendix_InBody Report Body Composition Index of 17 CountriesMaleCountryFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)1,169 24.28.5Argentina1,554 34.46.6140,099 23.89.0Australia256,044 33.57.247,768 24.08.7Canada50,416 33.36.93,060 27.68.7Chile6,570 38.26.887,288 21.98.3China114,097 28.96.3109,161 22.58.8Germany133,605 32.07.1195,744 27.28.2India133,898 37.06.7133,725 21.18.1Japan189,541 29.76.22,083,928 22.98.3Korea3,488,437 31.96.317,683 25.48.2Malaysia25,708 34.46.364,934 27.38.6Mexico108,858 37.2 6.853,476 21.38.8Netherlands67,105 32.47.12,603 26.18.6Saudi Arabia2,713 35.66.961,784 24.48.9South Africa83,091 36.97.011,721 22.48.3Thailand13,237 31.86.281,730 22.88.7U.K.99,549 33.97.0989,151 23.69.1U.S.1,435,420 35.87.2MaleArgentinaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)58322.68.420s429 33.16.534425.58.530s395 34.46.615726.68.740s433 34.16.86125.68.750s227 35.46.63126.88.560s66 396.6425.47.870s16 42.66.6MaleAustralia FemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)45,997 20.79.020s95,534 31.77.248,645 23.59.130s82,443 33.17.328,612 25.69.140s51,230 34.27.313,972 27.99.050s25,429 37.07.15,406 31.08.660s8,343 39.76.91,761 33.18.370s1,844 42.66.7*Thedatausedinthisreportwereusedsolelyforstatisticalpurposes,toprovideinformation,limitedtothedataforwhichpersonalinformationwasagreedupon,andnoinformationthatcanidentifyindividualsisincludedinthedata.41MaleGermanyFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)31,740 18.78.820s34,233 29.77.025,520 21.98.930s28,663 31.27.118,087 23.89.040s25,899 32.07.220,118 24.78.950s29,269 33.47.112,429 26.18.760s15,192 34.86.94,718 26.98.470s4,740 34.96.8MaleCanadaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)9,245 19.88.720s11,656 31.56.99,998 23.18.830s11,687 32.87.011,583 24.48.840s12,433 33.57.111,104 25.58.850s10,091 34.46.96,137 26.58.660s4,811 35.06.72,088 28.28.270s1,379 36.46.4MaleChileFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)777 26.28.520s1,873 37.96.81,245 27.78.730s2,362 37.86.8749 28.28.740s1,577 38.36.8290 29.28.750s693 39.16.750 29.28.360s176 41.16.710 31.58.570s17 41.06.2MaleChinaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)49,895 20.88.320s54,071 28.46.229,198 23.28.430s43,829 29.06.37,388 24.08.440s13,834 29.56.51,752 25.18.250s3,503 31.46.5321 25.47.760s443 32.86.453 29.37.770s159 35.86.3MaleIndiaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)97,347 25.58.020s59,295 35.96.666,575 28.38.330s44,011 37.06.926,628 29.58.340s22,220 37.96.97,246 31.38.250s9,132 40.16.81,044 32.88.060s1,692 41.86.7191 34.27.570s120 43.26.42024 InBody Report42Appendix_InBody Report Body Composition Index of 17 CountriesMaleJapanFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)46,861 18.88.220s58,938 29.06.135,235 21.58.230s49,572 29.86.226,444 22.48.240s40,013 30.06.316,313 22.78.150s27,870 30.46.27,777 23.27.860s11,222 30.16.14,372 24.37.470s6,395 30.45.9MaleKoreaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)990,286 21.58.320s1,347,141 31.46.2638,623 24.08.430s1,005,944 31.76.4305,818 24.38.440s676,040 31.76.5168,923 24.28.250s443,907 32.86.554,168 25.07.960s166,459 33.86.413,967 25.97.670s29,123 35.36.2MaleMexicoFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)21,892 25.18.420s34,533 35.56.722,555 27.28.730s35,790 36.76.812,775 29.08.840s21,680 38.07.05,917 29.88.650s12,638 40.06.92,486 30.28.260s5,294 40.76.6661 30.77.770s1,232 41.16.3MaleNetherlandsFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)18,003 17.68.720s19,247 29.77.012,707 21.08.830s19,247 31.77.29,529 23.08.940s14,162 33.07.38,681 24.68.950s13,561 34.97.24,547 26.18.760s5,568 35.67.01,375 27.38.470s1,397 36.26.8MaleMalaysiaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)6,449 23.38.120s8,079 33.16.16,234 26.28.330s9,096 34.76.43,184 26.88.240s5,577 35.06.41,509 27.48.050s2,479 35.86.2452 28.77.860s747 36.36.187 27.07.370s114 36.25.943MaleU.K.FemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)28,400 20.38.620s28,880 31.76.826,788 22.68.830s30,347 33.37.115,627 24.48.940s20,897 34.77.28,697 26.18.950s15,258 37.07.13,059 27.48.660s4,956 37.16.8790 27.78.370s1,144 36.96.6MaleSaudi ArabiaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of Skeletal muscle mass index(kg/)804 24.08.420s684 34.26.7916 26.18.730s887 35.06.9545 27.68.840s605 36.47.1271 27.98.850s415 37.07.1105 28.38.560s146 38.77.017 31.58.670s22 40.26.8MaleSouth AfricaFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)25,269 20.78.820s28,466 34.86.818,648 25.68.930s27,184 37.57.011,510 27.49.040s18,003 37.97.15,658 28.39.050s8,783 38.67.11,820 29.58.760s2,402 39.76.9366 30.88.370s335 40.56.6MaleU.S.FemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)348,426 20.59.020s399,306 34.07.1278,137 23.89.230s405,674 35.47.3189,881 25.59.340s320,999 36.27.3120,091 26.59.250s223,962 37.47.258,810 27.78.960s100,257 38.26.920,283 29.18.470s27,619 38.96.6MaleThailandFemaleNumber of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)Number of dataMean value of body fat percentage(%)Mean value of skeletal muscle mass index(kg/)5,142 21.68.220s4,859 31.76.24,407 22.78.430s4,746 31.36.31,821 23.38.340s2,518 31.66.3527 24.88.150s1,076 33.46.2107 26.37.560s244 34.65.922 29.67.270s30 37.25.72024 InBody Report44The copyright of the 2024 InBody Report is owned by InBody Co.,Ltd.Commercial use of this report is prohibited,and when citing,be sure to indicate the source.For inquiries about this report,please contact us below.InBody Public Relations TeamManager Kyung-woo,Lee Telephone:( 82)2-300-2226 E-mail:2024 InBody Co.,Ltd.retains all rights to this publication.IB-ENG-00-A-2401081 Fukuoka,Yuki,et al.Importance of physical evaluation using skeletal muscle mass index and body fat percentage to prevent sarcopenia in elderly Japanese diabetes patients.Journal of diabetes investigation 10.2(2019):322-330.2 Jensen,Michael D.Role of body fat distribution and the metabolic complications of obesity.The Journal of Clinical Endocrinology&Metabolism 93.11_supplement_1(2008):s57-s63.3 Norgan,N.G.The beneficial effects of body fat and adipose tissue in humans.International journal of obesity 21.9(1997):738-746.4 Carbone,John W.,and Stefan M.Pasiakos.Dietary protein and muscle mass:translating science to application and health benefit.Nutrients 11.5(2019):1136.5 Michaud,Pierre-Carl,et al.Differences in health between Americans and Western Europeans:effects on longevity and public finance.Social science&medicine 73.2(2011):254-263.6 Volpi,Elena,Reza Nazemi,and Satoshi Fujita.Muscle tissue changes with aging.Current opinion in clinical nutrition and metabolic care 7.4(2004):405.7 Kaufman,Jean M.,and Alex Vermeulen.The decline of androgen levels in elderly men and its clinical and therapeutic implications.Endocrine reviews 26.6(2005):833-876.8 Oliveros,Estefania,et al.The concept of normal weight obesity.Progress in cardiovascular diseases 56.4(2014):426-433.9 St-Onge,Marie-Pierre,and Dympna Gallagher.Body composition changes with aging:the cause or the result of alterations in metabolic rate and macronutrient oxidation?Nutrition 26.2(2010):152-155.10 Stenholm,Sari,et al.Body mass index as a predictor of healthy and disease-free life expectancy between ages 50 and 75:a multicohort study.International journal of obesity 41.5(2017):769-775.11 Wilkinson,Daniel J.,M.Piasecki,and Philip J.Atherton.The age-related loss of skeletal muscle mass and function:Measurement and physiology of muscle fibre atrophy and muscle fibre loss in humans.Ageing research reviews 47(2018):123-132.12 International Diabetes Federation(IDF),based on global diabetes prevalence as of 2021ReferencesDate of publication:January 08,2024Publishing:InBody Co.,Ltd.Publisher:CEO,Rami LeeDirecting:Kyungwoo LeeEditorial:Suyeon Yang,Heehwan KimDesign:Jiyoo ParkInBody Building,625,Eonju-ro,Gangnam-gu,SInBody Annual Report2022-2023Contents/Report2023 g
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