Last night Charlie Rose conducted a group interview of Robert Klein, campaign chair for the Calfornian Proposition 71 embryonic stem cell funding initiative, Brook Byers, partner at venture capital firm Kleiner Perkins Caufield Byers, and Susan Desmond-Hellman, president of product development for Genentech. The general area of discussion was about biotechnology and medicine. These three interviewees all agreed on one very important point: only innovation can solve the problems caused by high and rising health care costs. It was gratifying to see these figures make an argument that is familar to readers of my blogs. Scientific and technological advances will be the ultimate solutions to the rapidly rising costs of medical care.
The view that innovation is the solution to our health care cost problems is not a new one. The late Lewis Thomas M.D., who was director of the Memorial Sloan-Kettering Cancer Center and the author of many essays on biology, was making that argument decades ago. Later in his life in 1992 Thomas repeated the argument that only scientific advances can produce the treatments that will make the major diseases of our time cheap to treat.
To be sure, we do have some spectacular surgical achievements in the headlines--the transplantation of hearts, kidneys, livers, and the like--but these are what I have called halfway technologies, brought in to shore things up after the still- unexplained diseases of these organs have run their course. And these measures, plus the new advances in diagnostic precision, account for a large part of the escalating costs of health care today. It seems obvious, to me anyway, that the only practical policy for bringing down those costs will be by more and more basic research in biomedical science, in the hope and expectation that we can then begin to understand, at a deep level, the underlying events in human disease. Sooner or later I am confident that this will be accomplished, and I hope for the sooner.
In one of his Lives Of A Cell books (this is an old memory, forget which one, probably Lives Of A Cell: Notes Of A Biology Watcher) published some time in the 1970s Thomas noted that before the advent of effective treatments of tuberculosis the many tuberculosis sanitariums were very expensive to operate. But he pointed out that once effective drugs against TB were developed the vast bulk of the sanitariums were quickly shut down as their patients were quickly and cheaply cured of TB. Thomas contended that expensive treatments are expensive because they fail to fix the underlying causes of diseases and that just about any really effective treatment is going to be pretty cheap. I agreed with him then and decades later I've grown only more confident that he correctly saw the fundamental problem (far more important than tort law, regulations, tax law, government entitlements programs, or market failures) that that is the root of high medical costs.
"In my own early professional life when I was an intern on the wards of Boston City Hospital the major threats to human life were tuberculosis, tetanus, syphilis, rheumatic fever, pneumonia, meningitis, polio, septicemia of all sorts. These things worried us then the way cancer, heart disease, and stroke worry us today. The big problems of the 1930s and 1940s have literally vanished."
A few of those diseases have made a come-back of sorts. But all are still problems of much lower orders of magnitude than they were a century ago. But what is most important to note is that when effective treatments were found for them the costs of preventing and treating them became a small fraction of the costs that those diseases previously inflicted on their victims, families of victims, and the rest of society.
Aside: One surprise in the Charlie Rose show discussion came from the venture capitalist Brook Byers. Byers says there are multiple groups in the United States and England that are working on nanoscale-level devices for very rapidly and cheaply sequence whole human genomes. Byers expects this problem to be solved in a few years.
The solution to the problem of cheap DNA testing will lead to much lower costs for drug development. How? Well, one way is that during clinical trials it will be possible to use smaller sets of trial participants to check out which genetic patterns each drug works best and worst with. Also, many drugs are held off of the market because they are too harmful to some subsets of society who have particular genetic sequences. Clinical trial participants who have adverse reactions to new drugs will be able to have their DNA sequences checked to see if genetic causes for the adverse reactions can be identified. Then drugs that would otherwise never be sold to the public can be approved for use with subsets of the population who are genetically compatible with those drugs. We will each have drugs that we can't use due to some genetic variations we each have. But more drugs will be able to make it onto the market than can be approved today.
The ability to quickly identify which genetic sequences make some people have adverse reactions to a given drug or to have much higher responsiveness to a drug (e.g. because their liver doesn't break it down as quickly) will also allow drug developers to more quickly and easily puzzle out the mechanisms by which the drugs vary in how they interact with different people. The knowledge of the genetic variations involved in drug response differences will allow drug developers to build animal models of genetic variations that cause different reactions to drugs and to design drugs that eitehr work with a larger set of genetic variations or to design different drugs for different genetic variations.
Andrew G. Keeler, who until June 2001 was on the president's Council of Economic Advisers and has since returned to teaching at the University of Georgia, said the Clinton administration had also played with economic calculations of the costs of curbing carbon dioxide emissions, in its case to show that limiting emissions would not be expensive.
But it made available all of the assumptions that went into its analysis, he said; by contrast, the Bush administration drew contorted conclusions but never revealed the details.
"The Clinton administration got these lowest possible costs by taking every assumption that would bias them down," he said. "But they were very clear about what the assumptions were. Anybody who wanted to could wade through them."
This illustrates why I have a hard time feeling enthusiastic about major political figures.The Clinton Administration, personifying the very outgoing and brazen nature of its leader, was willing to lie in detail in public (yes, arbitrarily choosing every unprovable assumption to tip an argument in your favor is brazen lying). By contrast, the Bush Administration prefers to make its lies to the public in the form of simpler summary conclusions which seem aimed at shutting off discussion by providing little to discuss. In the first instance the advantage for critics of the Clintonites was of course that one could challenge each of the individual assumptions that went into building the big lie product. But it is as if the Clinton Adminstration operated under a "dishonesty in labelling" law (as distinct from a "truth in labelling" law) where they revealed all their deceptive ingredients. There is something more brazen about the Clinton Administration choice because a detailed lie is a larger scaled effort that requires more work to produce. More people have to agree to lie when the lie is going to be a detailed economic or ecological model.
Detailed lies remind me of how Spock would tell Captain Kirk some impossibly precise number (Spock: It is difficult to be precise, Captain. I should say approximately 7824.7 to one.) to give the illusion of having greater knowledge about a matter than it was possible to have. Perhaps in Star Trek this was acceptable since it was fiction. But the fact that the deception created an illusion in the minds of many audience members demonstrates that the technique works. The offering of elaborate details and great mathematical precision in results can be (and too often is) used as a technique for deception.
By contrast, the Bush Administration just asserts that its announcements of the truth are miraculously what makes their preferred choices the best choices. Is this worse? The downside is that it provides no basis from which to start arguing their conclusions. It tends to discourage public scrutiny of government decisions and it amounts to a simple assertion of "trust me". It is an approach that probably has the effect of reducing the amount of time the public spends thinking about public policy issues. Or perhaps it just causes a shifting to other policy topics as the public spends less time thinking about public policy issues the government doesn't want to have attract so much attention.
But which approach allows for a greater level of deception? Which is more effective? Is the human mind more easily fooled by simple lies or by complex lies? Perhaps it depends on the mind. Perhaps the deceptions of the Bush Administration are, at least on average, being pitched to a different target demographic group or audience than the Clinton Administration's deceptions were aimed at.
Of course the government has no monopoly on public policy deception. Various factions fool themselves and others into believing they are the virtuous ones presenting the real truth of the matter on some complex issue of policy. The actual act of debating some policy issue - even with the most honest of intentions - inevitably ends up being deceptive in some manner. One has to select what one thinks to be relevant facts (and hopefully correct facts) to present. That act of selection can cause one to deceive both oneself and others.
On the bright side technological trends strike me as favoring more accurate public policy discussions on issues involving science. We can so much more easily find information because of the ever improving world wide web and search engines. Anyone who Googles and reads the better web logs regularly can become far better informed on some issue than was possible even a few years ago. One can read multiple news stories from different sources on the same subject. One can go back to more original sources from which news stories are written. One can even contact scientists and other figures and ask for clarifications whereas previously only journalists could do that.
My sense of how things are going is that the quality of available information is improving and it is becoming easier to get better informed and less partisan analysis on any topic. Though there is still the challenge of how to find the best people on each topic.
William Happer, a professor of physics at Princeton University and George W. Bush supporter, says a lot of scientists are too stuck on their own intellectual superiority. (the magazine The Scientist requires free registration that is well worth the time to sign up for it)
Happer, a member of the Homeland Security Science and Technology Advisory Panel, suggested that the charges from the UCS and Nobel Laureates are largely overblown and out of context. He said that some scientists, who've garnered a sort of "deity complex" based on their scientific achievements, take their role to be akin to Plato's "philosopher kings," wise advisors who would tell citizens how to live. "They're extremely upset when the Bush administration doesn't call in the philosopher kings to be told what to do," he said.
When I hear some of the scientists who are angry at Bush Administration restrictions on embryonic stem cell research part of my reaction is that the scientists are seemingly opposed to the idea that anyone besides scientists should be able to decide what is ethical in areas where the scientists are working. This is something ultimately arrogant and condescending about their rhetoric. They can't see how anyone can legitimately disagree with them. Yet we face serious ethical issues with the ability to manipulate cells that have the potential to develop into full humans. It strikes me as immature to expect the public to all just jump and shift to the position held by most stem cell researchers just because the stem cell researchers are experts. Should we have a society which is ruled by experts?
Leave aside what you personally feel about ethical questions related to embryonic stem cell research. Look at the case of murder. Almost everyone agrees that murder is a bad thing and it should be outlawed. By contrast, there are sharp divisions in America and in many European countries over abortion. Why? It is hard to draw the line on what is a human now that we can intervene in areas we never had the ability to intervene in before. What principles should we use to guide us in making those decisions? Most scientists arguing for allowing the use of embryonic stem cells do not even try to provide an answer to that question. They just rag on Bush and those supposedly horrible fundamentalist Christians.
Religious folks do attempt to provide an answer for why they are opposed to both abortion and embryonic stem cell therapies: They think these procedures and manipulations kill spirits. Now, do we have spirits? Heck if I know. Hope so. Doubt it too. Is there a God who has set absolute rules for right and wrong? The scientists have no better idea to the answer for that question than do priests and pastors. Science is throwing up all sorts of cases where we have to decide on right and wrong where we never had to before because we couldn't create the conditions that produced the ethical problem in the first place.
It is a strain on the public to be faced with so many ethical issues on matters of such gravity. Scientists need to recognize this and to show some patience. That some people (whether for religious or non-religious reasons) tend to take a more expansive view of what is a human than some scientists desire is not a bad thing even if those people are wrong. Would you rather live in a society where the populace tends to draw too small a circle around what is human? Or would you rather live in a society where people err in the direction of greater protection? It is exceedingly unlikely you are going to live in a society where people make their judgements about rights with perfect precision and infinite wisdom. We are only humans after all.
It seems to me that a government has to be legitimate in the minds of its people and that legitimacy has to rest on a widely held set of beliefs on what is right and what is wrong. That need to come up with a consensus on moral questions can not always be avoided by oft-made claim that we can sidestep the need for consensus by letting each person decide whether, say, to make use of the ability to have an abortion or to use embryonic stem cells for therapy. The reason is that the debate is over the question of what is a rights-possessing entity. The answer to that question is by no means obvious. We hold now that babies are from the moment of birth rights-possessing entities. Killing a baby is murder. But back in the Roman Empire that was not the case. Down through time there have been many changes on where to draw the lines on what is a human and on what rights humans possess under different circumstances. So there is no obvious self-evident truth on what is murder or what is a human.
Scientific advances are going to create new situations to debate on where to draw the line and also provide information that will affect how we define where to draw the line. But science by itself can not provide ethical answers. Arrogant condescending assertions of what is right and wrong by academic biomedical researchers are no more helpful than similar assertions by their opponents. One can be a reasonable and well-informed person and disagree with either side. One can even be reasonable and well-informed and be deeply ambivalent about many of the questions that are arising as a result of biomedical advances.
What is a human? The stakes are incredibly high for how we answer that question. The stakes matter for not just abortion and embryonic stem cell research but also for genetic engineering of children, genetic engineering to increase the intelligence of other species, the development of artificial intelligence and human-computer interfaces, and with the ability to keep alive brain-dead or extremely cognitively decayed humans. Most of the ramifications of what happens if we make various choices are hard to guess at. But at least some of those choices would be disastrous in my view. For instance, imagine if we allowed any entity that can pass a Turing test full rights. This would likely be an appealing criterion for some scientists even though most people don't even know what a Turing test is. But then genetically engineered psychopaths would be free to prey on people until they were caught committing a crime.
So far secular scientists have not advanced a compelling non-religious basis for deciding what is a human. Carl Sagan suggested drawing the line (if memory serves) at the point at which the cerebral cortext begins development. His argument was that the frontal lobes of the brain are what makes human minds unique. But most scientists do not try to engage the question at that level. They just assert that of course any reasonable person could not possibly believe that a single cell deserves legal protection.
What I find more worrying about this state of the debate is not the arrogance of scientists. The bigger problem in the longer run comes from the intellectual demands that will be placed on anyone who is trying to judge whether some product of science really is something we want to recognize as sufficiently human-life to deserve protection as a human. The level of cognitive ability and of education even needed to understand the reasoning of arguments for some moral positions about what is a human and what is a rights-possessing entity will be so great that those arguments will be inaccessible to a substantial fraction of the population. How can we have a moral consensus on the legitimacy of crucial laws regarding what is murder and what is a human life if the population can't even understand the laws and their justifications?
One area of international competition involves patents. Americans still win large numbers of them, but the percentage is falling as foreigners, especially Asians, have become more active and in some fields have seized the innovation lead. The United States' share of its own industrial patents has fallen steadily over the decades and now stands at 52 percent.
A more concrete decline can be seen in published research. Physical Review, a series of top physics journals, recently tracked a reversal in which American papers, in two decades, fell from the most to a minority. Last year the total was just 29 percent, down from 61 percent in 1983.
The article cites a number of measures of relative decline of the US position. In some categories the centers of greatest expertise are clearly in other countries. At the same time the US is attracting fewer foreign graduate students and fewer of them are staying in the US once they graduate.
One possible response to this trend would obviously be to increase spending on basic research. But in the face of a huge budget deficit the Bush Administration is probably going to take the opposite step and increase the rate of US decline from its leadership position in science. See my previous post Bush Administration To Cut Many Categories Of Research Spending for the depressing story.
Another possible response would be to pursue an immigration policy which keeps out less intelligent people and makes it much easier for the smartest people to enter and stay in the United States. Of course, the idea of using IQ as a criterion for immigration admissions is incredibly politically incorrect in the United States at this point in time. But before the US falls even further in world ranks in science and technology and while we can still afford to pay to attract top talent we really ought to shift our immigration policy toward one where only the best and the brightest can get in. My posts on this subject are found in my ParaPundit category archive Immigration Brain Drain. As for the question of whether, if we only had the will, could we keep out the less bright the short answer is "Yes" and this could be achieved at an affordable cost if only the political will existed to enforce immigration laws. For a longer answer see my category archive Immigration Law Enforcement.
In some quarters there is a religious belief in the United States as inevitable world leader. I do not subscribe to this view. Powers rise and fall and the US is no exception. Lots of others centers of scientific and technical prowess are obviously rising. While that trend promises to be beneficial because of the resulting knowledge that will raise living standards and increase youthful life expectancy the world over it is clearly a signal that the days are numbered for US as sole "hyperpower". The current leadership in Washington foolishly concentrates too much on using existing power to pursue their short term goals (including doing any number of things to get themselves reelected that are financially harmful in the longer run) while warning lights are flashing that the US's future position will be far less mighty
To some extent the US is a victim of its own history of successes. When a country can succeed in spite of doing foolish things too often it happens that those foolish actions are pointed to as the reasons for success. The US has been lucky in many ways for centuries and therefore at least some Americans have had a tendency to embrace false myths to explain its successes (e.g. that all immigration is good or that God has specially blessed the place).
I see luck as a big factor in America's success. The US was lucky not to be conquered by Hitler or ruled by communists. It was lucky to be separated by oceans from the greatest military threats of the last few centuries. It was lucky to have lots of natural resources such as iron ore, coal, and oil and farmlands ideal for growing crops. It was also lucky to inherit some "cultural software" that Samuel P. Huntington has labelled as dissenting Anglo-Protestantism (which most of America's intellectuals now foolishly dismiss). These and other factors have given the US a pretty good run to the top. Some factors such as a fairly low level of government corruption, an effective legal system for protecting physical and intellectual property, and a free society continue to weigh in US favor today. But not all trends are favorable as the NY Times article linked to above shows.
American demographic trends combined with the adoption of more effective policies in many other nations (e.g. the economic liberalization in much of South and East Asia) are not favorable to the continuation of the US position of clear economic, technological, and, scientific, and military leader. Our room for error is getting smaller very quickly. It is not even clear that the wisest and most astute policies can maintain the current US position. The ratio of population between China and the US is so large that if the Chinese achieve even one fourth of the per capita productivity of the US then the US economy will cease to be the largest. Depending on whether you treat the EU as a single political unit (a debatable proposition) the US potentially already isn't number 1. Though at least in terms of an aging population the EU has an even bigger demographic problem than the United States
The US position is in some ways similar to the British position of the late 19th century. The British home islands population was too small to maintain their position of economic leadership and dominance of a world empire. Their leaders could have played their hand more wisely. Daniel Drezner argues that Germany gained on Britain in industry because the more decentralized structure of the German goverment allowed the regions to innovate in educational and science policy (PDF format) in ways that the British failed to do. But even a better played hand couldn't haved fix the Briitsh demographic Achilles Heel of having a smaller population than Germany and the United States. This is the position the US finds itself in today especially vis a vis China.
Drezner's point about the advantage of a decentralized structure of power speeding the rate of innovation in Germany in the late 19th century does not bode well for the US either (and probably bodes even worse for EU countries as Brussels gains more power). The states, burdened with Medicaid and other expensive federal mandates have lost a considerable amount of autonomy as Congressional legislation, court rulings, and regulatory agencies shift power toward the center. National mass media has tended to make all issues into federal issues to be solved by policy initiatives cooked up by national politiicans and inflicted on local schools and other lower level institutions. The growth of federal involvement in educational policy works against the development of local and state level educational policy innovations.
Aside from a smarter immigration policy and more federal funding for science what can be done about America's relative decline? One potential area for policy innovation is in how science is funded. Science is a classic public good. But it is a good for which it is hard to decide what to fund. One can't predict which research projects will pay off as easily as, say, one can predict which paths for highways will serve the most drivers. If incentives could be developed to encourage science funding by sources aside from the federal government then the distributed nature of the funding sources would reduce the harmful effects of the centralized setting of priorities. The rate of innovation may well increase as a consequence. Possibly tax law at the federal level could be changed to encourage more private philanthropy for science. A mechanism to provide state governments more incentive to fund science might also accelerate the rate of research and development.
Here's an idea for how to make the drive toward centralized regulation work to increase state-level innovation: when states and regions fail to achieve some federally mandated environmental regulatory goal the US Environmental Protection Agency can fine them. But instead of fining them and allowing the federal government to take the fine money how about allowing the states to spend that money on research into topics aimed at developing processes that do not pollute? How about setting a regulatory goal and then allow states to point to funding of research and development as a good faith attempt to achieve that regulatory goal?
Kei Koizumi, US federal R&D budget analyst for the American Association for the Advancement of Science (AAAS), claims that most categories of research and development spending will see inflation-adjusted declines in the Bush Administration's long-term budget plan through FY2009.
The president has proposed budget decreases at nine of the 12 federal agencies with the largest R&D portfolios, with only the Department of Defense (DOD), the Department of Homeland Security (DHS), and the National Aeronautics and Space Administration (NASA) staying ahead of inflation. Large projected increases in NASA and DHS obscures the steep cuts in all other nondefense agencies. In fact, DHS will see a $100 million increase from FY2004 to FY2005, with small increases projected each following year, culminating in a 25 percent boost and record-breaking funding levels over five years after adjusting for inflation.
Although the space exploration programs at NASA will benefit from large funding increases, all other R&D areas will decline dramatically over the next five years, including Earth Science (down 15.9 percent), aeronautics (down 16.2 percent), and Biological and Physical Research (down 11.8 percent).
AAAS analysis shows that even a past favorite like the National Institutes of Health (NIH) is susceptible to cuts. Over the next five years, NIH's $27 billion portfolio will see a modest rise due to increases in biodefense research. But funding for non-biodefense programs will fall by seven percent.
Many R&D funding programs face steep cuts over the next five years:
- Department of Energy (DOE) programs will see dramatic decreases such as: energy R&D (down 21 percent by FY2009), fossil energy R&D (down 22 percent), and energy conservation (down 26 percent).
- Department of Agriculture (USDA) intramural research will decline by 19 percent and extramural research grants will see a 28 percent cut.
- At the Department of Commerce, the Bush Administration would eliminate the Advanced Technology Program (ATP), as well as cut the budgets of the National Oceanic and Atmospheric Administration (NOAA) and the National Institute of Standards and Technology (NIST) by 10.5 percent and 17.3 percent respectively by FY 2009.
"In order to meet deficit reduction targets, even agencies receiving modest increases like NIH and NSF will see their R&D funding fall beginning in FY 2006," Koizumi said.
Why does Bush think the US can not afford to spend more on science? Lots of reasons. Bush has signed into law a prescription drug benefit that is going to cost $534 billion over the next decade (and that estimate is probably low if past Medicare entitlement spending estimates are indicative). This is especially worrisome because as government spending on drugs increases the pressure to implement drug price controls will increase as well. By reducing the profitability of new drug development and price controls would lead to a drop in private sector funding of medical research. Other entitlements for the elderly are set to grow. The Iraq war and occupation are adding hundreds of billions of more costs. Bush is effectively robbing the future to pay for more immediate demands of various interest groups and for his expensive foreign policy pursuits. See the chart at the bottom of the AAAS full report for how the projected changes in R&D fuding break out through fiscal year 2009. See here for other formats for the same AAAS report.
With the President's FY 2005 budget proposal, total federal R&D investment during the first term will be increased 44%, to a record $132 billion in 2005, compared to $91 billion in FY 2001.
President Bush's 2005 budget request commits 13.5% of total discretionary outlays to R&D - the highest level in 37 years. Not since 1968 and the Apollo program have we seen an investment in science of this magnitude.
Of this, the Bush budget commits 5.7% of total discretionary outlays to non-defense R&D. This is the third highest level in the last 25 years.
Funding for Basic Research, the fuel for future technology development, is at an all-time high of $26.8 billion in FY 2005, a 26% increase from FY 2001.
The President has completed the doubling of funding for the national Institutes of Health (NIH). Funding for NIH during the four years of this Administration is increased more than 40% since FY 2001 to $28.6 billion.
Funding for NSF during the four years of this Administration is increased 30% over FY 2001 to $5.7 billion.
The White House leaves out the fact that most of the NIH budget doubling occurred during Clinton's term in office and was done in large part because some Republican and Democratic party US Senators decided it was a wise thing to do. Some of those Senators have since left office and NIH budget growth doesn't appear to be as well supported politically at this point. Sorry I don't have a URL for this brief aside on NIH budget politics but I read an account of how it happened a couple of years ago.
The White House also ignores what it intends to do in specific categories and what it intends to do out beyond FY2005. The growth in NASA spending and Department of Homeland Defense spending is hiding cuts in other areas.
In my view most of the increase in NASA spending is a waste. The only exception is the plan to develop a nuclear powered space probe which will help to enable the development of defenses against asteroids. There are higher science priorities with much bigger financial and quality-of-life payoffs than a mission to the Moon and Mars.
Biological research can lengthen our lives, make us healthier, smarter, and generally more capable. The biological research will eventually produce treatments that will extend youth and middle age. This will increase the length of time that people can work and therefore would allow us to entirely avoid the financial catastrophe of tens of billions of dollars of unfunded liabilties for care for the elderly that is looming as a growing fraction of the population becomes too old to work. The acceleration of anti-aging and rejuvenation research is the best way to solve the demographic problem of aging populations. See Aubrey de Grey's writings on strategies of engineered negligible senescence for a roadmap of the types of research we ought to be pursuing that could save us tens of trillions of dollars in money that will otherwise have to be spent on the aged. The ability to reverse aging will also unleash huge increases in productivity and economic growth that would produce orders of magnitude more wealth than the cost of the research spent to make it possible.
Energy research in another area which can pay itself back many times over. Newer energy technologies will reduce trade deficits, make our air healthier to breathe, and reduce the threat of terrorism by reducing the financial flows to the Middle East. Another benefit will be greatly reduced defense costs. Instead of cutting energy research we ought to launch a major effort at an additional $10 billion dollars per year aimed at obsolescing oil by pursuing research into a number of alternatives. While Bush purports to be big on national defense he misses the obvious point that energy policy is an essential element of national security policy and energy policy is going to become more important for national security in the future.
The Bush Administation's plans for research and development spending are short-sighted. Scientific advances can solve problems in ways that pay back orders of magnitude more than the original research will cost to fund. Budget deficits and huge unfunded liabilities for those who are going to become elderly in the coming decades combined with the threat of terrorism and the greater globall competition for a limited supply of oil call for mammoth attempts to research and innovate our way to solutions.