When I was an undergrad in the mid 90s, I kept hearing about the advances in medical research, cancer cures, antivirals and so on, which were just around the corner, waiting to be marketed, thanks to the advances in molecular biology, genetics and immunology. A Golden Age is coming soon, you’d would have to be forgiven to think. And still… almost twenty years have passed, and these advances are yet to be materialized. New, promising vistas have turned up since then, however, with new promises and new technologies. It seems like a Golden Age is just around the corner. Again.
However we still have the same shitty small molecule medicines, there is no personalized medicine in sight, and most importantly: no cure for cancer (some advances in managing some tumor types have been made, to be fair, but most of it still depends on cutting the fucker out early), there are no effective antivirals (OK, HIV is a manageable disease now, I give you that), no cures for genetic disorders, no gene therapy, no explanation what causes Alzheimer’s, MS, and all those other ugly and dangerous conditions which force people to live in hell on earth. Cancer and heart disease are still the greatest killers, and you know what? We can’t even make a bloody artificial heart. I mean what’s the big deal with the heart? It’s a freaking pump. We have smart bullets that navigate, we have GPS, we sent a space craft out of the Solar System, we made phones that have more computing power than the whole Apollo Program, we have the internet, pizza delivery, Xbox One, virtual reality set for chicken, we can reanimate rappers and pop stars, and we still cannot change a simple thing like the heart. I don’t care about flying cars. I want artificial organs and limbs. So what’s going on?
Why is this happening? (Or, more accurately, not happening?) Why could humanity create a nuclear bomb in a couple of years from scratch, crack the Enigma code, put man on the Moon, yet making sure that your immune system will not condemn you to paralysis and death by eating off the myelin from your nerves is still impossible? Interesting question, isn’t it? What will our descendants think of us when they look at how we, as a civilization, spend our money? The way we spend reflects our priorities; and if we look at the numbers, these priorities don’t seem to be the right ones. Military spending generally outweighs the amount of money spent on science. In the US (let’s single the poor bastards out for the sake of simplicity; the trends are similar in every Western democracy anyway) only about $30 billion goes to the NIH which is responsible for the majority of research funding in life sciences. To put this into perspective, the military got $680 billion in 2009. Obviously we like our weapons more than our health. Paranoia, perhaps some repressed feelings about size of certain gonads might account for this disparity; also the fact that there are a lot of people getting really rich producing weapons (and by making sure they are used regularly). But this post is not about bashing the famed Military-Industrial Complex. This post is about something else: how to organize and fund medical research the most efficient way? I think the answer is simple (spoiler alert): go Manhattan Project on their ass.
Let’s look at how medical research is conducted presently, and take a look at all those big projects (Manhattan Project, Apollo Program) which yielded immense results in a short time. If we can see where the difference lies, perhaps we can arrive to some useful conclusions. Presently most basic research is conducted in academic institutions, funded by government bodies. Charities also give a lot of money, and sometimes rich people donate a truckful of money if they become personally involved in some debilitating disease; but basing your long-term strategic planning on the possibility that a rich guy falls off his horse is clearly not the way to do it.
Research is usually done by small laboratories in the most part, focusing on small projects, jealously guarding their results, performed by overworked postdocs and graduate students. This work is supervised by stressed out PIs, or worse, MDs, who use the research funding they get to get out of the clinic, and are completely ill-equipped for the most part to do meaningful research. Not all MDs are House, but research councils and other funding organizations are obviously not aware of that, and this can be felt as MDs get increasingly larger slice of a very small (and shrinking) cake.
There are serious concerns about relevance and reproducibility of academic research, as the current funding mechanisms produce quite perverted incentives. (Somehow the Chicago school management did not work out in Academia. It’s really weird, because it did not work out anywhere, yet, surprisingly, it utterly failed in an academic settings as well. Who the hell would have thought? This enigma still puzzles decision makers and administrators, and they work real hard to remedy the situation by applying the same theory even more… perhaps if they try hard enough, it will eventually give up and work.) Additionally the short-term contracts make sure that no person can actually devote him or herself to a topic for decades in the postdoc level, which would allow them to actually do something useful. Instead they have to keep moving on every three of five years to a different lab, different project, and most likely, different country. And don’t forget: they are the primary drivers of research; they are the guys staring at those tubes. You think a professor would stare at a tube? They’re too busy writing grants, standing next to blackboards, waving their hands in front of students, and staring at postdocs staring at tubes. I think most everyone sees the problems with efficiency here. The whole “publish or perish” attitude from the funding bodies and administrators also warped the priorities; when my lab has a discussion about potential projects, the focus is not on “doing good science”, but on “how to do experiments that can be published in the journal with the highest possible impact factor“. The difference is subtle but there, and added up with other factors, like the issues with peer-review, it produces an incredible amount of rubbish. Administrators assume that high impact publications equal good science (this has some serious ramification on your future), but this is frankly bullshit, and it seems like nobody have yet enlightened them of their error. Nobody today would fund a guy who wants to extract proteins from jellyfish, or think deep thoughts about the Higgs Boson. And even if the research is sound, statistics might not be as reliable as you think.
So these are the foundations on which medical research is built. They are shaky to say the least.
Pharmaceutical companies, on the other hand, can afford to focus on certain areas, and spend billions on finding cures and treatments. Never mind that most of that money goes for advertising; the problem is they themselves have some seriously warped incentives in choosing the areas to research. Antibiotics are out, because they are cheap, but the expense of research is still astronomical. Better focus on chronic conditions and treatments (not cures, mind you) which can be sold over the lifetime of the patient. So there’s that. You might be dying of a simple infection in twenty years, because all our present antibiotics will worth nothing at the present rate of research and evolution multidrug resistant bacteria, but rest assured you can die peacefully knowing there were a lot of people making money on type two diabetes treatments instead of researching antibiotics that could cure you in a week. It’s a wonder, to be honest, that there are any advances in medical science at all.
Haphazard, uncoordinated research, low funding, and greedy companies do not make good science. And yet, when we, as a species, put our minds to it, we can get shit done. Worried that the Germans will get an A-bomb? Let’s build one in less than three years! (Considering the costs, by the way, there never was a realistic chance that Germany could build one; not even in peace time.) Want to crack the Enigma messages? Build computers, get hundreds and hundreds of people together, and get to it! The Germans themselves created some astonishing pieces of technology (rockets, jets, guided missiles, etc) while engaged in a two-front war. Worried that the Nazi scientists in Russia will put a man on the Moon before the Nazi scientists in the US do the same? Get to work, throw some money on it, and finish by the end of the decade! We are worried about smallpox rearing its ugly head over and over again? Vaccinate the fuck out of the entire world! We can get things done. Even things that look impossibly difficult at the time. (Don’t forget, the first Moon landing happened 64 years after the first powered flight… Not exactly a long time.)
So what is different? Why was NASA so successful, and why are we still unable to heal hay fever? It’s the central will, central funding and central organization that makes the difference. Although many people reading this will probably collapse in a socialism-induced seizure, but these projects were possible, and they were successful because there was a strong governmental role in them. None of that “free-market solves” everything nonsense, which has been proven to be incorrect and detrimental for most of the time (as if there were free markets…), but a central decision of getting shit done. A government or an intergovernmental body decided to accomplish something, threw a shitload of money on the problem, set up the facilities, and got on working. They were not concerned about share holders and quarterly reports about profitability, they did not care about “immediate impact” and other buzzwords funding bodies like to use; they went against a problem, and kept hitting it in the face until they won. You want a “cure for cancer”? (Yeah, I know it’s not one disease. Stop distracting me.) Build an institute, equip it, fill it with scientists who are on a permanent contract, set up an oversight committee composed of people with scientific background, fund them without forcing them to spend their work hours on idiotic grant proposals, and keep pouring the money in until they are done. On the long run, they will be more efficient and produce more results than under the present circumstances. Corruption is an issue with every government projects, you say? Because it’s not an issue with private contractors, as we well know. Corruption is always a problem if there’s no regulation, regardless of the nature of the endeavour. There are countless of examples of wasting the public’s money in both the public and the private sector. Lots of big government projects are essentially designed to be a free-for-all buffet for friends and relatives; but it does not prove anything. The truly gigantic projects (under New Deal, Manhattan Project, Apollo, etc) were surprisingly low on the corruption scale. Perhaps someone nicked a space-rock or two, but nothing comparable to the problems around the Panama Canal, or Mr Richard Cheney’s old company’s shenigans in Iraq. The key word here is regulation. That disgusting word again, that is an anathema for all those who grew up on Atlas Shrugged, and were not smart enough to realize it’s a worse piece of fiction than Winnie the Pooh. If there is a strong oversight, there will be no corruption. Yes, there are some cases when the private sector rose up to the challenge. There’s the Tesla car, and there’s space faring rockets. However, these are exceptions to the rule: these projects worked because a bunch of dot-com billionaire nerds decided not to give a fuck, and poured incredible amounts of their own personal wealth into a dream. As with the falling rich guys, this is not something you should be counting on for every important field we need improvement on.
What would be the end-product of such a big medical Manhattan Project? (Aside from countless of discoveries, and cure for all sort of cancer, you mean?) If we look at the Apollo Program, we got a crapload of benefits (aside from chaps playing golf on the Moon; you cannot put a price-tag on that); the Manhattan Project propelled the world into a new age of energy (and weaponry). Mr Turing and his group of geeks gave us the computer (before he was forced to grow breasts which drove him to suicide, that is). The New Deal gave us the Intracoastal, the Hoover Dam and all the other crucial pieces of infrastructure that is currently crumbling because, you know, free market. A gargantuan research project of similar proportion would yield advances in science that would open the way for new frontiers new marketable discoveries. It would create cures that could form the basis of successful pharmaceutical companies under governmental control. The last bit is important, because we want those taxpayers benefit from the discoveries. Groundbreaking research drives innovation; tools and technologies need to be developed to support this research, which would spur a new wave of discoveries. These new technologies can also make profit in the form of spin-off companies. In other words: on the long run it would be worth the taxpayer’s money, even if we don’t take into account the fact that we cure a lot of these very taxpayers of hitherto incurable diseases. Also, as an indirect benefit, this money would not be spent on weapons. As sad as it sounds, if the US, for example (poor sods I keep singling them out), decided to throw the F-35 into the dustbin and spend the amount of money it poured into that piece of crap into cancer research, we would most likely already be immortal. Sure, the blockheads in the military would be denied of a boner-inducing warplane, but on the plus side, there would be more people living a productive life. The military guys will need to contend themselves of using older airplanes to kill people. Maybe we could pay for some premium accounts on War Thunder as a compensation. (By the way, did you see the shit they’re forcing their pilots to wear? Stuff of nightmares.)
So what is holding us back? Why can’t we pull of the same stunt as we did with all the other, already mentioned projects? Simple. The lack of threat. The US needed a nuclear bomb, because some people realized it could be necessary to win the war. (It wasn’t, in the end, but sure it came handy later.) Computers were necessary because the bloody Germans had a very sophisticated cypher mechanism which needed to be cracked constantly if Britain was to survive without reverting to cannibalism. Apollo was necessary because the two superpowers got into a dick-waving contest about reaching the Moon (and polishing their ICBM technology in the meantime). Pox vaccination was prudent, because the Western World realized it will not be safe from this ancient killer as long as those poor brown people still kept dying from it. (Don’t forget, before the effective vaccination virtually everyone in this world was guaranteed a round of Russian roulette with the virus, with two bullets in the chamber. The mortality was about 30% in Europe, and up to 90% in the Americas.) All of these cases had an underlying threat that needed to be tackled. But not all threats are equal; after all climate change is really going to mess our days up, but it’s not an acute threat. It will happen in a few decades, most likely to our children, not to us. Not to mention it will happen to poor people first, anyway. In the meanwhile a lot of people will keep getting rich by derailing the (scientifically already settled) debate, in order to make sure that no action is taken. So the threat has to be acute, and big enough to make sure that special interests cannot kill the incentive, and convince people that they actually have to do something instead of sitting on their lazy asses in front of a flat-screen TV. Perhaps if we invented an alien civilization that is planning to take over the world by spreading cancer, we would get somewhere. The sad thing most likely we will not do anything. We’re just a bunch of short-sighted monkeys unable to see what is wrong with us. Tragedy of the commons, my ass.
Don’t look at me like that.
OK, rants off.
(Hm, maybe this whole personalized treatment really is around the corner. But I’m still right, you know.)