Today we're joined by one of the most thought-provoking voices in all of medicine, Dr. Jay Bhattacharya, director of the biggest medical research organization in the world, the National Institutes of Health. As a Stanford University trained professor, physician, and economist, Dr. Bhattacharya has dedicated his career to the economics of healthcare, the ethics of policy decisions, and the impact they both have on every individual. Which begs the question, how can free societies navigate public health crises without sacrificing the very freedoms they want to protect?
From Ballard Studios in the nation's capital, it's 13th & Park.
Doctor, great to have you on the show today. We were just joking about what I should call you—doctor, professor. You certainly are teaching America a lot about things that they just don't know about. It must feel like every day you get up, you can't wait because you know you're going to engage in something completely fresh.
It is a really interesting, exciting job. I mean, there's definitely some downsides, but on the other hand, this opportunity to actually fundamentally transform how science works, to change public health in this country for the better, and to rebuild the trust in it after the failures of COVID—who could pass that up? It's an amazing, amazing chance.
Well, you were not a bit player in COVID, and we're going to get to that in a second. But let's talk first about the National Institutes of Health. It's the largest medical research organization on earth, and its mission is dedicated to health and longevity. So why is it that, Doc, our longevity numbers have been flat or down? Why is it we spend more money than any other nation on earth on healthcare and still we are where we are, which is far from where we need to be? What's wrong with what's going on today?
There's a bit of irony in this. So we are the leading nation in the world of biomedicine, and NIH plays no small role in that. It's been responsible for so many of the breakthroughs in fundamental biomedicine. A large chunk of the drugs that we take are based on NIH research. And so you would think that we would be the healthiest country on earth, but we're not. In fact, there's a chronic disease crisis, as you know, and as you just said, life expectancy actually hasn't gone up in this country. Our life expectancy is at the same level as it was in 2012. It's been flat, really. Of course, there was a big decrease during the pandemic and it went back up, whereas a whole bunch of other countries have continued to see increases in life expectancy. We are very bad at translating this fundamental biological knowledge we have into health for people. And that's the reason why the MAHA idea is so attractive to me and to millions of other people, because what we want is that scientific know-how to be translated into better health for us and better health for our kids and into the future, in ways that don't bankrupt us, which it does now.
How do we compare to the rest of the world, Doc, in terms of longevity right now?
We're far behind. You just take a look at the Japanese—I think their life expectancy is into the 80s, and we're at about 78, 79. Among all the developed countries on earth, very close to last place. Just think about that. Just think how shocking that is. What that means is that we are rich but not healthy. I was born in India. Just to give some context, when I was born in 1968, the life expectancy of boys in India was something like 48. In the United States, a boy born today, I think, is like 74, 75, something like that. So that looks like tremendous progress over the last 55, 60 years, and it is tremendous progress. But if you compare that with a boy born in Belgium or France or Germany or Sweden or Japan, they're likely to live into their 80s. And the United States, in many ways, we have structured our culture in ways that don't promote health. That's the reason for MAHA. We don't fully understand why. There's economic incentives, of course, but then there's medical incentives. The healthcare system is structured to take care of the sick rather than prevent illness in the first place. Lots and lots of complicated things. The NIH needs to be a part of the solution to that and hasn't been.
Well, one of your partners in MAHA obviously is Dr. Oz, the CMS administrator, who was on this show recently. Fascinating guy. He said something that really struck a chord with me. He said, at CMS, if we think we're doing everything right, we're failing. It really parallels what you have said. Quote: 'We have a scientific culture that doesn't recognize how difficult science actually is. It punishes failure too sharply and has the wrong standards of truth.' So, let's start with the punishment of failure. How could it be that we have structured the health care system around the idea that only rewards success, which means you can't try anything unless you have a near certainty it's going to work?
You got it exactly right. So the contrast is with something like Silicon Valley. Imagine your job is to find a portfolio of investments that's going to produce the next Google or the next Apple or whatever. You're not going to be evaluated based on every single element of the portfolio. In fact, your job is to take risks on behalf of the people that you work for, to identify projects that look like they might be promising, but you don't know. So you fill your portfolio with like 50 projects, 49 of them fail and the 50th is Google. You're seen as an enormous success.
And the culture is such that all those 49 companies that failed, if they're productive fails, they learn from their failures, then they get a second chance.
There you go. Biomedicine is very different. You're a young researcher. You have an idea. It's very difficult to get support to try it out. You have to work as a postdoc in somebody's lab, and you're working really for them, not for you. If you do try it out and it doesn't work out, you're not going to go forward in biomedicine. It's a very different kind of environment. At the NIH, the NIH has like 27 different institutes and centers and stuff. They're all led by world-class scientists. Their job is kind of like a VC—to pick a portfolio of scientific projects that they think would be cool and interesting and productive. If 49 of their projects fail and the 50th cures cancer or cures type 2 diabetes or something, they're going to be seen as a failure because, oh, your 49 projects failed. It's a very difficult environment to make advances because we are too conservative. And the NIH has become way too conservative over the past decades. In the 80s, we were supporting ideas that were zero, one, two years old. That was the typical NIH portfolio. Now, we're supporting ideas that are seven or eight years old because we fear failure too much.
Well, you've spoken a lot about replication of test results, but what you're really saying is there's an incentive right now in the system not to go back over work that's already begun by someone else's signature. And you even have a tough time having that published in medical journals. In fact, some would say it's nearly impossible. Which means this: you have an originator of an idea and then there's the validator or validators of an idea. Both should be valued equally, right? Because if all we are looking for are originators and not validators, we're never going to validate anything as real, as truthful, or that works. Isn't that where it is?
You're absolutely right. Okay, we just talked about risk-taking in science, and we're saying we don't encourage enough novel exploration in science the way we do in Silicon Valley or something. But on the other side of it is exactly what you said. We also don't reward people who do the basic work of science—validating and checking the work of others. It sounds so mundane, but it's actually pretty fundamental. The idea is, how do we decide what is true in science? If we think about where we are now, we decide what is true in science based on authority. Are you published in a top journal? Well, that's an appeal to authority. Are you a top scientist at a big institution? Well, that's an appeal to authority. It has vast ramifications for our culture. So like the newspapers and the media pick up ideas that are seen as true, because really what they're doing is elevating authority. In science, the real basis of truth is validation—independent people looking at the same work you do, same idea, same question, maybe looked at it from a different angle, find the same answer. There you go. What we need is a replication reformation of science where we invert what is the basis for truth. Instead of authority, which is where it currently is, it should be ground truth, ground reality.
How do you change the culture of thinking and lead us to what I think you've called a tolerance for failure, which intuitively—well, wait a minute, why should we abide by or be okay with failure? Because you have to fail a lot sometimes to find that magic answer. It's that one in 50 ideas you referenced from Silicon Valley. How do you change the way we think about things so that we can get there culturally, to enable us to actually start from the ground-up ideas into play?
There's a couple ways to do this. First, you have to give the people who choose the scientific portfolios an incentive to actually do the things that they know how to do, which is make investments in promising things and don't punish them so much for failure. Exactly what I'm doing at the NIH. I've made a change to the way that the scientists who decide on these portfolios of investments can choose. We have a scientific review panel, which is a fantastic peer-review organization. They decide the scientific merit of each project. They're very conservative—they emphasize is it a good project based on is it likely to succeed. They tend to punish innovation, like a new idea might threaten their work. I'm going to start evaluating the work of the folks who run these institutes based on: does the portfolio succeed in advancing health? Does it fundamentally transform biological knowledge? It's going to give them strong incentives to pick things that are new ideas, promising things that the field right now thinks isn't going to work, but it's worth investing in. And even if it fails, I'm not going to punish them. The valuation is based on: does the portfolio improve the health of Americans? Does it change our fundamental knowledge of biomedicine?
The other side of it is replication. We're going to start funding scientists who do independent replication for a living. And we're going to start rewarding scientists whose work is subject to replication. We'll start doing baseball-like metrics—do they share their data? Should they share their code? Right now scientists have these baseball-like metrics, but it's just how many papers have you published? How many citations have you got? So, you have a revolution in science from two different directions. One, we'll start to reward novelty more than we currently do, bring young scientists in more than we do. And then on the other side, to reward people who do the basic fundamental work of validating the work of others.
