healthcare
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The next healthcare revolution will have AI at its center
The global pandemic has heightened our understanding and sense of importance of our own health and the fragility of healthcare systems around the world. We’ve all come to realize how archaic many of our health processes are, and that, if we really want to, we can move at lightning speed. This is already leading to a massive acceleration in both the investment and application of artificial intelligence in the health and medical ecosystems.
Modern medicine in the 20th century benefited from unprecedented scientific breakthroughs, resulting in improvements in every aspect of healthcare. As a result, human life expectancy increased from 31 years in 1900 to 72 years in 2017. Today, I believe we are on the cusp of another healthcare revolution — one driven by artificial intelligence (AI). Advances in AI will usher in the era of modern medicine in truth.
Over the coming decades, we can expect medical diagnosis to evolve from an AI tool that provides analysis of options to an AI assistant that recommends treatments.
Digitization enables powerful AI
The healthcare sector is seeing massive digitization of everything from patient records and radiology data to wearable computing and multiomics. This will redefine healthcare as a data-driven industry, and when that happens, it will leverage the power of AI — its ability to continuously improve with more data.
When there is enough data, AI can do a much more accurate job of diagnosis and treatment than human doctors by absorbing and checking billions of cases and outcomes. AI can take into account everyone’s data to personalize treatment accordingly, or keep up with a massive number of new drugs, treatments and studies. Doing all of this well is beyond human capabilities.
AI-powered diagnosis
I anticipate diagnostic AI will surpass all but the best doctors in the next 20 years. Studies have shown that AI trained on sizable data can outperform physicians in several areas of medical diagnosis regarding brain tumors, eye disease, breast cancer, skin cancer and lung cancer. Further trials are needed, but as these technologies are deployed and more data is gathered, the AI stands to outclass doctors.
We will eventually see diagnostic AI for general practitioners, one disease at a time, to gradually cover all diagnoses. Over time, AI may become capable of acting as your general practitioner or family doctor.
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Startups should look to state-of-the-art tech to tackle diseases affecting women
Startups devoted to reproductive and women’s health are on the rise. However, most of them deal with women’s fertility: birth control, ovulation and the inability to conceive. The broader field of women’s health remains neglected.
Historically, most of our understanding of ailments comes from the perspective of men and is overwhelmingly based on studies using male patients. Until the early 1990s, women of childbearing age were kept out of drug trial studies, and the resulting bias has been an ongoing issue in healthcare. Other issues include underrepresentation of women in health studies, trivialization of women’s physical complaints (which is relevant to the misdiagnosis of endometriosis, among other conditions), and gender bias in the funding of research, especially in research grants.
For example, several studies have shown that when we look at National Institutes of Health funding, a disproportionate share of its resources goes to diseases that primarily affect men — at the expense of those that primarily affect women. In 2019, studies of NIH funding based on disease burden (as estimated by the number of years lost due to an illness) showed that male-favored diseases were funded at twice the rate of female-favored diseases.
Let’s take endometriosis as an example. Endometriosis is a disease where endometrial-like tissue (‘‘lesions’’) can be found outside the uterus. Endometriosis is a condition that only occurs in individuals with uteruses and has been less funded and less studied than many other conditions. It can cause chronic pain, fatigue, painful intercourse and infertility. Although the disease may affect one out of 10 women, diagnosis is still very slow, and the disease is confirmed only by surgery.
There is no non-invasive test available. In many cases, a woman is diagnosed only due to her infertility, and the diagnosis can take up to 10 years. Even after diagnosis, the understanding of disease biology and progression is poor, as well as the understanding of the relationships to other lesion diseases, such as adenomyosis. Current treatments include surgical removal of lesions and drugs that suppress ovarian hormone (mainly estrogen) production.
However, there are changes in the works. The NIH created the women’s health research category in 1994 for annual budgeting purposes and, in 2019, it was updated to include research that is relevant to women only. In acknowledging the widespread male bias in both human and animal studies, the NIH mandated in 2016 that grant applicants would be required to recruit male and female participants in their protocols. These changes are slow, and if we look at endometriosis, it received just $7 million in NIH funding in the fiscal year 2018, putting it near the very bottom of NIH’s 285 disease/research areas.
It is interesting to note that critical changes are coming from other sources, and not so much from the funding agencies or the pharmaceutical industry. The push is coming from patients and physicians themselves that meet the diseases regularly. We see pharmaceutical companies (such as Eli Lilly and AbbVie) in the women’s healthcare space following the lead of their patients and slowly expanding their R&D base and doubling efforts to expand beyond reproductive health into other key women’s health areas.
New technological innovations targeting endometriosis are being funded via private sources. In 2020, women’s health finally emerged as one of the most promising areas of investment. These include (not an exhaustive list by any means) diagnostics companies such as NextGen Jane, which raised a $9 million Series A in April 2021 for its “smart tampon,” and DotLab, a non-invasive endometriosis testing startup, which raised $10 million from investors last July. Other notable advances include the research-study app Phendo that tracks endometriosis, and Gynica, a company focused on cannabis-based treatments for gynecological issues.
The complexity of endometriosis is such that any single biotech startup may find it challenging to go it alone. One approach to tackle this is through collaborations. Two companies, Polaris Quantum Biotech and Auransa, have teamed up to tackle the endometriosis challenge and other women’s specific diseases.
Using data, algorithms and quantum computing, this collaboration between two female-led AI companies integrates the understanding of disease biology with chemistry. Moreover, they are not stopping at in silico; rather, this collaboration aims to bring therapeutics to patients.
New partnerships can majorly impact how fast a field like women’s health can advance. Without such concerted efforts, women-centric diseases such as endometriosis, triple-negative breast cancer and ovarian cancer, to name a few, may remain neglected and result in much-needed therapeutics not moving into clinics promptly.
Using state-of-the-art technologies on complex women’s diseases will allow the field to advance much faster and can put drug candidates into clinics in a few short years, especially with the help of patient advocacy groups, research organizations, physicians and out-of-the-box funding approaches such as crowdfunding from the patients themselves.
We believe that going after the women’s health market is a win-win for the patients as well as from the business perspective, as the global market for endometriosis drugs alone is expected to reach $2.2 billion in the next six years.
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Back to the suture: The future of healthcare is in the home
The pandemic has highlighted some of the brightest spots — and greatest areas of need — in America’s healthcare system. On one hand, we’ve witnessed the vibrancy of America’s innovation engine, with notable contributions by U.S.-based scientists and companies for vaccines and treatments.
On the other hand, the pandemic has highlighted both the distribution challenges and cost inefficiencies of the healthcare system, which now accounts for nearly a fifth of our GDP — far more than any other country — yet lags many other developed nations in clinical outcomes.
Many of these challenges stem from a lack of alignment between payment and incentive models, as well as an overreliance on hospitals as centers for care delivery. A third of healthcare costs are incurred at hospitals, though at-home models can be more effective and affordable. Furthermore, most providers rely on fee for service instead of preventive care arrangements.
These factors combine to make care in this country reactive, transactional and inefficient. We can improve both outcomes and costs by moving care from the hospital back to the place it started — at home.
Right now in-home care accounts for only 3% of the healthcare market. We predict that it will grow to 10% or more within the next decade.
In-home care is nothing new. In the 1930s, over 40% of physician-patient encounters took place in the home, but by the 1980s, that figure dropped to under 1%, driven by changes in health economics and technologies that led to today’s hospital-dominant model of care.
That 50-year shift consolidated costs, centralized access to specialized diagnostics and treatments, and created centers of excellence. It also created a transition from proactive to reactive care, eliminating the longitudinal relationship between patient and provider. In today’s system, patients are often diagnosed by and receive treatment from individual doctors who do not consult one another. These highly siloed treatments often take place only after the patient needs emergency care. This creates higher costs — and worse outcomes.
That’s where in-home care can help. Right now in-home care accounts for only 3% of the healthcare market. We predict that it will grow to 10% or more within the next decade. This growth will improve the patient experience, achieve better clinical outcomes and reduce healthcare costs.
To make these improvements, in-home healthcare strategies will need to leverage next-generation technology and value-based care strategies. Fortunately, the window of opportunity for change is open right now.
Five factors driving the opportunity for change
Over the last few years, five significant innovations have created new incentives to drive dramatic changes in the way care is delivered.
- Technologies like remote patient monitoring (RPM) and telemedicine have matured to a point that can be deployed at scale. These technologies enable providers to remotely manage patients in a proactive, long-term relationship from the comfort of their homes and at a reduced cost.
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Y Combinator-backed Adra wants to turn all dentists into cavity-finding ‘super dentists’
Like other areas of healthcare, the dental industry is steadily embracing technology. But while much of it is in the orthodontic realm, other startups, like Adra, are bringing artificial intelligence into a dentist’s day-to-day workflow, particularly in finding cavities, of what will be a $435.08 billion global dental services market this year.
The Singapore-based company was founded in 2021, but was an idea that started last year. Co-founder Hamed Fesharaki has been a dentist for over a decade and owns two clinics in Singapore.
He said dentists learn to read X-rays in dental school, but it can take a few years to get good at it. Dentists also often have just minutes to read them as they hop between patients.
As a result, dentists end up misdiagnosing cavities up to 40% of the time, co-founder Yasaman Nematbakhsh said. Her background is in imaging, where she developed an artificial intelligence machine identifying hard-to-see cancers, something Fesharaki thought could also be applied to dental medicine.
Providing the perspective of a more experienced dentist, Adra’s intent is to make every dentist “a super dentist,” Fesharaki told TechCrunch. Its software detects cavities and other dental problems on dental X-rays faster and 25% more accurately, so that clinics can use that time to better serve patients and increase revenue.
Example of Adra’s software. Image Credits: Adra
“We are coming from the eye of an experienced dentist to help illustrate the problems by turning the X-rays into images to better understand what to look for,” he added. “Ultimately, the dentist has the final say, but we bring the experience element to help them compare and give them suggestions.”
By quickly pointing out the problem and the extent of it, dentists can decide in what way they want to treat it — for example, do a filling, a fluoride treatment or wait.
Along with third co-founder Shifeng Chen, the company is finishing up its time in Y Combinator’s summer cohort and has raised $250,000 so far. Fesharaki intends to do more formalized seed fundraising and wants to bring on more engineers to tackle user experience and add more features.
The company has a few clinics doing pilots and wants to attract more as it moves toward a U.S. Food and Drug Administration clearance. Fesharaki expects it to take six to nine months to receive the clearance, and then Adra will be able to hit the market in late 2022 or early 2023.
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Medical supply marketplace startup bttn. sews up additional $5M seed
Coming off a $1.5 million seed round in June, bttn. announced Thursday that it secured another $5 million extension, led by FUSE, to the round to give it a $26.5 million post-money valuation.
The Seattle-based company was founded in March 2021 by JT Garwood and Jack Miller after seeing the challenges medical organizations had during the global pandemic to not only find supplies, but also get fair prices for them.
“We went into this building on the pain points customers had dealing with a system that is so archaic and outdated — most were still faxing in order forms and keeping closets full of supplies, but not knowing what was there,” Garwood, CEO, told TechCrunch.
Bttn. is going after the U.S. wholesale medical supply market, which is predicted to be valued at $243.3 billion by the end of 2021, according to IBISWorld. The company created a business-to-business e-commerce platform with a variety of high-quality medical supplies, saving customers an average of between 20% and 40%, while providing a better ordering and shipping experience, Garwood said.
It now boasts more than 300 customers, including individual practices and surgical centers, and multiple government contracts. It is also currently the preferred supplier for over 17 healthcare associations across the country, Garwood said. In addition to expanding into dental supplies, bttn. is also attracting customers like senior living facilities and home and hospice care.
Garwood intends to use the funds to expand bttn.’s technology, sales and operations teams, and increase its partnerships. The company is also adding new features like a portal to track shipments more easily, better order automation and improve the ability to control when supplies will get to them.
Bttn. is also analyzing more of the data coming in from its marketplace to recognize where the trends are coming from, including hospitalization rates, to share with customers. For example, if hospitals are overcrowded, supply shortages will follow, Garwood said.
“The medical supply industry was built on inequity, and we have a sense of duty to build a product that enables a better future for our customers,” he added. “We can proactively let customers know that spikes are expected, provide them with correct information and give that power back to the consumers and healthcare providers in ways they never had before.”
Whereas bttn.’s first seed round was “about pouring gas on the fire,” partnering with FUSE this time around was an easy decision for Garwood, who said the firm is bringing new assets to the table.
Brendan Wales, general partner at FUSE, said via email that his firm backs promising entrepreneurs building businesses in the Pacific Northwest and discovered bttn. before they announced any funding.
He said there is massive consumerization of healthcare, most evident on the patient side for years, but now becoming so on the provider side. Medical office employees are looking for the same type of customer experience they get from online businesses they frequently shop at, and bttn. “has a relentless drive to provide the same type of experiences and interactions to health providers.”
“We fell in love with the idea of providing a transparent and delightful customer experience to health providers, something that has been sorely lacking,” Wales added. “That, tied in with a young and ambitious team, made it so that our entire partnership worked tirelessly to partner with them.”
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How to establish a health tech startup advisory board
When you enter the health tech industry as a new startup, an advisory board is a crucial foundational step. A board can guide you through industry-specific nuances, help you make important decisions and prove your legitimacy to investors looking for a strong industry background.
An advisory board will be able to give you strategic insights about both your company and the wider healthcare and technology industries.
In my experience of raising capital, the unpredictable financial situation at the beginning of the pandemic meant we nearly lost our $2 million round, but came through with a committed $250,000, which we used to bring in about $500,000 in revenue.
Something that helped this process was building our advisory board and starting small — we didn’t go for all of healthcare but instead focused on two healthcare verticals. This allowed us to prove our concept, build case studies and win contracts with specific teams in our customers’ companies.
It pays off to stay focused and prove your worth so that your advisory board members can champion you in niche markets, with the potential to expand in the future. For this reason, it’s important to identify the main intention behind your board, and exactly who should be on it.
Who to recruit
Three to five people is an ideal starting point for an advisory board, depending on the size and stage of your company. In health tech, you need more than just the healthcare perspective — you also need the insight of those who have already grown technology companies, perhaps outside of the industry. Our company’s board is an even split of two healthcare and two technology advisers, and, ideally, you want to find a fifth who is well versed in both industries.
It pays off to stay focused and prove your worth so that your advisory board members can champion you in niche markets, with the potential to expand in the future.
An M.D., a Ph.D. from a respected institution or a thought leader in your relevant field of healthcare is the most important asset to an advisory board. These are the highly decorated physicians who have strong connections and act as a reference for their peers.
They provide instant credibility for your company, help you get into the minds of both patients and healthcare providers, and can outline how various health systems work.
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The gray revolution: Fundraising within the older adult space
The technology industry is often thought of as being the domain of the young and the new. We see an emphasis on young founders (“40 Under 40”), innovative ideas and disruptive challenges to legacy brands, incumbent companies and “old” ways of thinking.
But one of the things I’ve learned on my journey in co-founding my latest startup is that technology should be enabling and accessible to all, and nowhere is this more critical than for empowering our older adults.
Older adults are one of the most underrepresented audiences for new technology products and platforms. There is a massive opportunity to provide products and services that will make life better for today’s seniors and future generations of older adults to come. Founders in every space, from edtech to healthcare, from financial services to robotics, can make a bigger impact if we recognize the opportunity of being of service to older adults.
One of the best strategies for tech companies that want to serve the older adult market is to focus your value proposition on empowering older adults.
Don’t make a product “for old people”
Older adults often get overlooked by tech companies. In fairness, it can be hard (and insensitive and uninspiring) to market products and services as being “for old people,” because people in this group don’t tend to think of themselves as “old.”
One of the best strategies for tech companies that want to serve the older adult market is to focus your value proposition on empowering older adults. Don’t make a product “for old people” — make a product that helps older adults lead a healthier, more active, more connected life.
Whether it’s the education tech space, financial services, health tech, consumer products or other innovative digital services for seniors, tech companies have big opportunities to empower older adults.
We are seeing some great examples, including:
- AgeBold is doing interesting work with at-home exercise programs for older adults to improve their balance, strength and mobility. The value proposition: Exercise for better aging. It’s a product “for” older adults, but the message is focused on empowerment and building strength, helping people live healthier, more active lives as they age.
- Eldera.ai connects children with vetted older adult mentors, for one-on-one or group conversations and remote learning activities. This concept is powerful because it helps older adults share their life experience and build relationships with other families.
Older adults have so much to offer. Instead of approaching this market as a “problem” to be solved, startups should engage with older adults as an active, curious, ready-to-learn group of people who are eager to be empowered.
Recognize the size of the opportunity of the older adult market
It often seems like so many consumer-facing apps today are created for younger people. But there’s a big disconnect between where so much of the tech industry’s attention and investment is going and the spending power and lifestyle preferences of today’s older adults.
Older adults are the most underserved demographic for the tech world. They’re also one of the fastest-growing age cohorts. The number of people worldwide who are 65 and older is expected to grow from 524 million in 2010 to 1.5 billion in 2050.
The “silver economy,” driven by the spending power of older adults, is expected to grow into the 2030s because the senior population is the wealthiest age group and their numbers are growing 3.2% per year (compared with 0.8% for the overall population).
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Google update will allow digital COVID-19 vaccination cards and test results to be stored on Android devices
Google is making it possible to store digital versions of either COVID-19 test results or vaccination cards on users’ Android devices. The company on Wednesday announced it’s updating its Passes API, which will give developers at healthcare organizations, government agencies, and other organizations authorized by public health authorities the ability to create digital versions of tests and vaccination cards that can then be saved directly to the user’s device. The Passes API is typically used to store things like boarding passes, loyalty cards, gift cards, tickets and more to users’ Google Pay wallet. However, the Google Pay app in this case will not be required, Google says.
Instead, users without the Google Pay app will have the option to store the digital version of the COVID Card directly to their device, where it’s accessible from a home screen shortcut. Because Google is not retaining a copy of the card, anyone who needs to store the COVID Card on multiple devices will need to download it individually on each one from the healthcare provider or other organization’s app.
The cards themselves show the healthcare provider or organization’s logo and branding at the top, followed by the person’s name, date of birth and other relevant information, like the vaccine manufacturer or date of shot or test. According to a support document, healthcare providers or organizations could alert users to the ability to download their card via email, text, or through a mobile website or app.
In an example photo, Google showed the COVID-19 Vaccination Card from Healthvana, a company that serves L.A. County, However, it didn’t provide any other information about which healthcare providers are interested in or planning to adopt the new technology. Reached for comment, Google says there are some other big partners and states in the pipeline, but it doesn’t have permission to share those names at this time. Over the next few weeks, some of these names will be released, we understand.
The Passes API update doesn’t mean Android users can immediately create digital versions of their COVID vaccination cards — something people have been taking pictures of as a means of backup or, unfortunately in some cases, laminating it. (That’s not advised, however, as the card is meant to be used again for recording booster shots.)
Rather, the update is about giving developers the ability to begin building tools to export the data they have in their own systems about people’s COVID tests and vaccinations to a local digital card on Android devices. To what extent these digital cards will become broadly available to end users will depend on developer adoption.
For the feature to work, the Android device needs to run Android 5 or later and it will need to be Play Protect certified, which is a licensing program that ensures the device is running real Google apps. Users will also need to set a lock screen on their device for additional security.
Google says the update will initially roll out in the U.S., followed by other countries.
The U.S. is behind other markets in making digital versions of vaccination cards possible. Today, the EU’s COVID certificate, which shows an individual’s vaccination status, test results or recovery status from COVID-19, went live. The certificate (EUDCC) will be recognized by all EU members and will aid with cross-border travel. Israel released a vaccine passport earlier this year that allows vaccinated people to show their “green pass” at places that require vaccinations. Japan aims to have vaccination passports ready by the end of July for international travel.
In the U.S., only a few states have active vaccine certification apps. Many others have either outright banned vaccine passports — which has become a politically loaded term — or are considering doing so.
Given this context, Google’s digital vaccination card is just that — a digital copy of a paper card. It’s not tied to any other government initiatives nor is it a “vaccine passport.”
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Dispense with the chasm? No way!
Jeff Bussgang, a co-founder and general partner at Flybridge Capital, recently wrote an Extra Crunch guest post that argued it is time for a refresh when it comes to the technology adoption life cycle and the chasm. His argument went as follows:
- VCs in recent years have drastically underestimated the size of SAMs (serviceable addressable markets) for their startup investments because they were “trained to think only a portion of the SAM is obtainable within any reasonable window of time because of the chasm.”
- The chasm is no longer the barrier it once was because businesses have finally understood that software is eating the world.
- As a result, the early majority has joined up with the innovators and early adopters to create an expanded early market. Effectively, they have defected from the mainstream market to cross the chasm in the other direction, leaving only the late majority and the laggards on the other side.
- That is why we now are seeing multiple instances of very large high-growth markets that appear to have no limit to their upside. There is no chasm to cross until much later in the life cycle, and it isn’t worth much effort to cross it then.
Now, I agree with Jeff that we are seeing remarkable growth in technology adoption at levels that would have astonished investors from prior decades. In particular, I agree with him when he says:
The pandemic helped accelerate a global appreciation that digital innovation was no longer a luxury but a necessity. As such, companies could no longer wait around for new innovations to cross the chasm. Instead, everyone had to embrace change or be exposed to an existential competitive disadvantage.
But this is crossing the chasm! Pragmatic customers are being forced to adopt because they are under duress. It is not that they buy into the vision of software eating the world. It is because their very own lunches are being eaten. The pandemic created a flotilla of chasm-crossings because it unleashed a very real set of existential threats.
The key here is to understand the difference between two buying decision processes, one governed by visionaries and technology enthusiasts (the early adopters and innovators), the other by pragmatists (the early majority).
The key here is to understand the difference between two buying decision processes, one governed by visionaries and technology enthusiasts (the early adopters and innovators), the other by pragmatists (the early majority). The early group makes their decisions based on their own analyses. They do not look to others for corroborative support. Pragmatists do. Indeed, word-of-mouth endorsements are by far the most impactful input not only about what to buy and when but also from whom.
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Musculoskeletal medical startups race to enter personalized health tech market
As the pandemic unevenly roars on, Emily Melton, founder and managing partner of Threshold VC, is reflecting on a previous public health crisis: the Spanish flu.
She says the response just over a century ago prompted the rise of interventional medicine — treating illness through surgery or medicine only after symptoms manifest. Today, interventional medicine is the dominant mindset in Western healthcare. And, Melton, a lead investor in health tech startups including Livongo, Tia and Calibrate, says the care pathway ages well.
Personalized medicine — the buzzy yet powerful framing growing in popularity among Silicon Valley startups — is a delivery system in which patients receive more holistic care that takes into account multiple symptoms or comorbidities.
“What’s happening in our society? Chronic diseases, chronic pain, diabetes and obesity,” she said. “That doesn’t require a magic pill and there’s not just a surgery. Oftentimes, there’s therapeutic components, behavior changes and movable touch points.”
Enter personalized medicine. The buzzy yet powerful framing is growing in popularity among Silicon Valley startups. It’s a delivery system in which patients receive more holistic care that takes into account multiple symptoms or comorbidities. In hormonal health, for example, personalized medicine could add more data and specificity to which birth control someone takes, instead of the usual process of trial and error. Essentially, it’s the opposite of interventional medicine.
“We’re not just an arm or a leg, we’re not just obese or a diabetic or a pain sufferer,” Melton said. “How do we treat you as a whole person?”
A number of companies are using this approach to reinvent care for patients with musculoskeletal (MSK) medical conditions and chronic pain. These conditions are commonly treated with addictive opioids, a major public health concern. As an estimated 50 million Americans suffer from chronic pain, entrepreneurs are working on solutions that don’t resemble the cookie-cutter status quo. And the money market is certainly there: In 2017, the global MSK medical market was valued at $57.4 billion; the market for chronic pain, which overlaps with MSK medicine, is expected to hit $151.7 billion in value by 2030.
“Oftentimes it’s not new ideas, it’s conflating a number of factors that come together at one moment in time that allow exponential change that makes a startup work,” Melton said, of the boom and recent activity in MSK medicine. Today, we’ll focus on three startups taking different approaches to help people suffering from chronic pain and MSK-related conditions: Clearing, PeerWell and Hinge Health.
Clearing
Avi Dorfman says going direct to consumers is the most effective way to treat chronic pain, so he founded Clearing. The digital health startup worked with a medical advisory board of physicians and researchers from Harvard, Johns Hopkins and NYC’s Hospital for Special Surgery to create an opioid-free solution for people struggling with pain.
Last month, Clearing raised a $20 million seed round led by Bessemer and Founders Fund. Melton also invested in the round on behalf of Threshold.
Clearing offers four products: prescription compound cream that includes FDA-approved ingredients, CBD cream for topical discomfort, nutraceuticals to supplement joint health, and a directory of prerecorded, at-home exercises. It currently is available to patients in California, Florida, Georgia, Illinois, New York, North Carolina, Ohio, Pennsylvania, Tennessee and Texas.
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