The Gutting of America's Medical Research
nytimes.com
nytimes.com
The current research system has serious problems, but we need accurate criticism to build a better future. "YC is all wasteful spending; why doesn't YC just choose to only fund the hits?" is absurd, but somehow we allow this argument when discussing NSF/NIH/DOE/DARPA.
It’s not a business. Its job is clearly outlined in the preamble of the constitution.
That or they would rather simply ignore biology in service of this or that politically-motivated special interest, and put off any problems for the next generation to deal with.
Just to reiterate a few things, while estimates vary, every $1 spent on medical research returns multiple dollars of economic value. One study out of England suggest that for ever pound invested in medical research, the return is .25 pounds every year after, forever. [1] The cost of these cuts, as others have said, is quite large.
In addition, these grants are peer reviewed by expert panels, and only grants that score within certain top N percentiles which are determined each year. For the marquee grants, you have to score in the top ~10th percentile (see [2], for example.) This scoring is done by expert panels, which are composed of leading experts / professors from around the country. While one can adjust funding priorities, part of the price to pay for having cutting edge basic research always available is that there will be certain things one disagrees with.
There is plenty of room for a discussion of how to increase the efficiency of scientific funding, and if the current science-funding institutions are at... 'a near-optimal position in tradeoff space.' However, taking a chainsaw to the agencies to punish them is like blaming doctors for outbreaks of diseases, the latter being sadly predictable.
[1] https://www.kcl.ac.uk/news/health-research-offers-a-big-retu...
[2] https://www.niaid.nih.gov/grants-contracts/niaid-paylines
Once again we are proving the US is just "I got mine, the rest of you can suffer" Country.
Examples are research on ALS, Childhood Diabetes and Cancer and many more issues too numerous to list. Already funding has been cut for ALS and Cancer research.
Welcome to depending upon China and Japan for ground breaking treatments. From what I have read Japan has been doing a lot and I think China is ramping up quickly.
Very likely those opinions will be shaped by social media and LLMs steering in turn public health policies, plugging into politics and back to start.
A neat vertically integrated system.
That's very double-edged.
The open question is should humans have the right to take substances individually?
Sure, you get Ivermectin/covid deniers. But you also get homemade Solvaldi (cure for Hepatitis C). I can make it for $300 for the 12 week course, and it retail costs $84000
Of course, even making and taking this drug you manufacture is illegal, even aside patent bullshit.
https://news.ycombinator.com/item?id=42538903
But why shouldn't I be able to treat myself? Why do we accept really shitty gatekeepers (medical establishment, doctors) gatekeep treatments and cures from us?
And more currently, now that der fuhrer quit the emergency use allocation for Covid shots, now you need a doctors scrip for 'allowing to get a vaccine'. I should be able to get this if I pay for it. But nope, now need to pay for needless doctor payment and more barriers.
So at least in that side, I'm on Qanon's view that I should be able to personally treat myself with whatever substance I deem. Of course, I'll definitely heed a doctor's suggestion as an expert. But fuck.. My body, my choice.
Consider this analogy: you should be allowed to put a gun to your own head and pull the trigger. You should not be allowed to put on a suicide vest and blow yourself up in a group of people.
We have a 'right' drink a handle of whiskey a day, up to the point we get liver disease. Same with smoking 3 packs a day of cigarettes. Same with horrendous diet. But those ways of killing yourself are "acceptable" and also legal. But they're slower.
The second, you're harming other people. That example is blatantly ridiculous, and appears just to gain an emotional response by invoking terrorism.
Have you watched a movie lately? Talk about contagious violence. I can tell you this, your fate is just a blip on the back side of other people's large screen TV where the movies are shown.
It ends so many stupid discussions we have in the US. Can this medication be prescribed for an off-label use? Who cares because you can just buy it. Do you meet some arbitrary federal weight guideline for Ozempic? Who cares you can just buy it.
* every rule has exceptions, don't get bogged down with them.
In that situation (the only one at this time), is the majority of resistances are made.
Controlling the supply, especially if you know you have a bacterial disease, can be solved readily.
In fact, on a camping trip, I was bit by 15 ticks. Was bad. When I got back to civilization, I started getting spots all over my body. Surprise, it was rocky mountain spotted fever. But if I could determine the 2 drugs for curing spotted fever and Lyme, I absolutely would have did both. But the shitty gatekeeper (doctor) wouldn't do Lyme course. Again, logically made a lot of sense, especially that Lyme tests are 60% accurate. And, 15 ticks.
Hard to create a strain of antibiotic resistant bacteria when you didn't have any in your system to begin with. Turns out you can't #gatekeep #girlboss your way out of this and have to educate your way out regardless if antibiotics are behind-the-counter non-prescription or not.
Antibiotic Resistance.
Longer explanation: how do you know exactly which bacteria you’re infected with, and which antibiotics will work well against them, and which ones they’ll throw a middle finger at? Even if you have the exact same symptoms as the last time, how do you know that taking the same antibiotic will work just as well, and won’t just further select for bacteria it has no effect on?
I believe all recreational drugs should either be legal or else available by prescription with the explicit statement in the law that addiction management is a valid reason for a prescription. None of the controlled substances hoops. And I think *renewing* maintenance meds should be within the realm of the pharmacist.
But I think all agents for which resistance is a factor should be doctor only.
This is great and all but it ignores that getting an antibiotic prescription is not difficult at all. I literally just get in a video call, describe the symptoms of strep, and they write me a prescription. It's less expensive to treat than to test. In 15 years I've never had a doctor actually test me for what bacteria I actually have. They sometimes do the bare minimum of looking at it to be pretty confident it's bacterial but that's about it.
However stupid you think the general populace is, doctors count themselves among their numbers. Your average urgent care or primary care doc is just going to give the same broad spectrum antibiotics without any real thought. Except for the one bona-fide MD who looked at my very obvious case of strep, knowing from my chart that I have chronic bacterial sinusitis, and me telling them as much, looking at my puss filled tonsils and concluding that it's allergies and that I should take Claritin. Never go to urgent care man.
Like, covid shots. Now you need to beg a doctor to get them. Hope you pass their gatekeeping test.
Or now women are being arrested and charged with murder for miscarriages and missing periods.
And there's another round of "get rid of ACA, which includes banning non-coverage of preexisting conditions. Treating yourself is a strong protection of not being covered.
RFK is going through medical records across the country for anybody with autism, ADD, and ADHD. What and how are these lists being used for? (I know how the German nazies used them...)
My body, my choice.
A problem that only exist in USA, you could follow literally any other country and you wouldn't get the same problem, and no other country avoided that issue but letting dumb people take dumb things that they heard in the internet
This is not true.
In the United States GENERALLY SPEAKING you can manufacture any substance that is not on the list of controlled substances on the CSA Schedule.
You cannot sell it or administer it to others.
Also IN GENERAL you can consume any substance that is not illegal to possess or manufacture.
In the non-pharmaceutical realm there are a few additional restrictions, like ethanol (which you can manufacture for industrial use but not human consumption) and various nuclear, biological, and chemical munition components. (Don't know how many people are ingesting those)
If you have the ability, you can manufacture your own sofosbuvir and ingest it.
You cannot sell or give it to anyone else.
We don't know what could've happened, but we do know what did happen. It's like those people that say that the New Deal was bad, actually, and if we did nothing that would be the same or better!
Right... but no. Because the New Deal did pull us out of the depression. It's one of the most potent and effective pieces of policy in American History. We can play armchair economist all day. But we have to face what we know worked and think about why it worked.
I would add that weird ideas can be surprisingly useful; nobody expected research on gila monsters to lead to our most successful weight loss treatment to date.
There are problems with this system. Researchers often have to spend a lot of time writing grant applications, and grants can be rejected for any number of bad reasons. And there are cases where research was funded that probably shouldn't have been funded. But research funding isn't given willy-nilly to whoever asks, and taxpayers wasting money on kooky ideas isn't a particularly big problem.
Patents last for about 25 years, but important innovations have returns far into the future, hundreds of years. At that rate, you would very often be better off accumulating interest on capital anyways.
Notwithstanding the nature of scientific progress as an accumulation of smaller experiences (each individually harder to justify with a profit motive).
Indeed, even privately funded research is often openly published, such as the now-famous paper "attention is all you need". There's just not that much to gain from keeping every single thing under wraps. More to gain with openness.
It's also not practical to keep those facts as trade secrets over the several decades over which their applications need to develop. Even if an industry consortium was willing to discover that clouds are made of water droplets, it would certainly leak before the science of meteorology had progressed far enough for that consortium to offer saleable rain forecasts.
Finally, companies are unwilling to train people about basic facts. Academia is the only system where "and then you tell everybody" is a part of the incentive structure. Privately, you have a strong incentive to reveal nothing and punish leakers.
More realistically, what would happen would be that rather than sacrificing themselves for the greater good in some kind of voluntarily socialist outpouring of wealth, they'd ask us to look to China for our scientific future.
An example is the superconducting supercollider. Chemistry and pharma industry were making NMRs cheaper and the cost of the supercollider components went down. So the LHC was a much more effective "buy" than the SSC.
To imply that private companies reap the rewards of basic research without contribute much is ignoring the many other components of translational work.
Second, biotech/pharma actually already do invest quite a lot in R&D. But they tend to focus on translational work rather than speculative exploration, because it is less risky.
Edit: as a follow up (because I feel like I strawmanned you), I am just trying to say that p-hacking is not always malice or incompetence. Sometimes limited methods/theory miss confounding variables, sometimes labs lack resources, etc.
... but it won't be.
Talking about rebuilding after just shifts this problem instead of solving it. When you start to spin things back up, who's at the front of the line looking for new grant money?
Most research is still following a medical model that worked for infectious diseases in the 1950s but does not yield any meaningful information or treatments for chronic, complex disorders that have multiple interrelated factors.
And since doctors are trained primarily in the treatment of acute diseases, even the useful information that’s found by research is largely ignored in practice. The ignorance of the average MD about chronic illnesses is astounding.
I’ve been sick for the last two years and I’ve given up going to doctors. They are a waste of my time. I’ve done much better by doing my own research and treating myself. Much of what’s helped has been stuff that I’ve seen described as pseudoscience, even though it’s empirically based, because there aren’t enough RCTs for it to qualify as “evidence”. This makes me incredibly angry.
The system is utterly broken. I’d like to scrap the whole thing and start over. Hopefully, we’ll find a way to start over when the smoke clears.
1. By way of self-inflicted damage
> More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.
https://www.commonwealthfund.org/publications/issue-briefs/2...
That was a lie to justify insurance price gouging.
Funding the research privately increases costs to end user as private ensurer is directly accruing more cost. Research stopping increases costs to end user as new/novel cures/treatments aren't found.
Cost for consumer goes up because of lost opportunity cost of 1) learning to diagnose earlier 2) finding new or cheaper cures/treatments.
You can make the argument 'But other countries will pick up the slack!' - but that doesn't necessarily help either, why would they give us the results of their research cheaper? US already jacked up pricing via an executive order on drug pricing just this year to knock that.
Publicly funded medical research is an absolute positive for the US general public health and wallets. We're all losing here on both ends of the spectrum ($$ and actual general public health).