Science & medicine are a monopoly
It might be hard to believe but science & medicine are caught in an innovator’s dilemma. This concept describes how an incumbent loses its edge to a disruptor because the incumbent focuses too much on what makes it successful now rather than what will make it successful in the future.
How can this be with so many advances happening all the time? It’s because the “customers” of science & medicine — the general public — are losing out. In the innovator’s dilemma, the value to customers when plotted as a function of time is a S-curve. Late in the innovation cycle there isn’t enough value being delivered to enough customers so the curve flattens out. As the COVID pandemic made clear, the problem is there is a monopolistic “company” that charges too much money and makes it too difficult on its “customers”.
What is the monopoly I’m referring to? It’s a cabal of entities largely in the US. Its regulatory agencies such as FDA and CDC, insurance companies such as United Healthcare, funding agencies like the NIH, and publishers such as NEJM and the Nature journals. Though there are sibling entities in other countries — let’s be honest — the US dictates much about what happens in science & medicine around the world.
Besides unsatisfied customers, how do we know U.S.A., Inc. has existential problems? Look no further than its own “employees”. Complaints by US scientists and doctors (disclosure: I am one) about the monopolistic practices of our “employer” have grown hopelessly long. We have spilled too much ink on the abuses to be able to summarize here. Why don’t these complaints change anything? This is why the innovator’s dilemma exists. Science & medicine is a monopoly too locked into its own “success”.
DeSci is anti-trust
Herein I argue if there were an alternative financial path for scientists and doctors where our time would be better spent, we would follow it. That path is DeSci. DeSci stands for decentralized science. Today it’s a nascent idea. But it’s an idea that has the potential for scientists and doctors to have a bigger impact because we’d be bringing our talents to the whole world. The whole world to fund our research. The whole world to benefit from our treatments.
Decentralized = alpha
DeSci takes its name from the first industry disrupted by crypto a.k.a. web3, finance. Decentralized finance (DeFi) applications use smart contracts and cryptocurrencies to perform a variety of financial services. DeFi is powerful because these crypto tools significantly improve upon traditional financial (tradFi) services. Take for example the tradFi staple — a savings account. Banks provide less than 1% yield on savings accounts whereas DeFi applications often provide 5–50% yields.
In finance, one’s returns or yield relative to those of the market are described as “alpha”. The whole point of “decentralized” is to maximize yield by not being restricted by geography. What does yield look like for DeSci? Basic research and clinical medicine have different goals so let’s consider them separately.
How the “De” in DeSci can improve clinical medicine
Yield in clinical medicine means more shots on goal — more new drugs and more clinical trials. For DeSci to make these a reality we need a few things:
1. Demonstrating the advantages of decentralized clinical trials (DCT). DeSci pioneers need to adopt a willingness to test a new drug wherever in the world can get the trial done the quickest and most economically, yet also safely. This will almost assuredly not be in the US. The FDA already has a huge backlog of projects to deal with. Only those with the most resources can get through it. Instead, we need to look to people and organizations elsewhere in the world who have a greater sense of urgency and where barriers to entry are lower. For example, perhaps a DCT trial for a new ALS treatment could involve doctors and patients in both New Zealand and Uruguay because of the high prevalence of this condition in these countries? Besides more quickly connecting more doctors around the world to the latest treatments, to make DCTs work we also need to develop a remote-first mindset in trial design. Meaning, we must strongly consider whether trial participants need to go get expensive and burdensome testing in the hospital as is typically done in the US-based trials. Or rather, whether at-home monitoring e.g., using more accessible approaches like smart phone apps or low-tech solutions could suffice.
2. Focusing on going-to-market over patents. In the incumbent system the costs of drug development are prohibitively high ($billions and 5–10+ years) and growing all the time. Patents are needed in this system to protect one’s investment because it takes so much time and money until gains can be realized. But what if patents aren’t necessary? As said above, DCTs will make the main cost driver of drug development — clinical trials — cheaper and take less time. At some point if a therapy is cheap enough and enough doctors and patients to prefer it, other drug companies won’t be able to undercut it — patent or no patent. Going-to-market first will win out over protectionism like it does in other sectors of the economy.
With crypto, profits also aren’t necessary. There’s no shareholders to pay dividends to. There’s no CEO pushing an agenda. Crypto represents a fundamental change in how people align incentives where contributors and value creators are compensated without the burden of having to pay middlemen and corporate overlords. So how does this profit-less system work? It works because with crypto the overhead is significantly less and at the same time it has significantly more tools than tradSci does in its financial toolbox to sustain itself and reward its participants. Crypto projects have tokens, can tap into DeFi, and can use tokenomics. The point is these things can be engineered to ensure funds last and can go back into funding more trials. Not only that, they can be engineered out in the open so that anyone who wants to participate can. It’s a more fair system for everyone.
How the “De” in DeSci can improve basic research
Yield in basic research means more funding for research and less time spent by researchers on non-research activities. To make DeSci a reality in basic research we need a few things:
1. Achieving funding levels that rival those offered by tradSci grant agencies. The DeSci ecosystem has to be capable of functioning independently of legacy systems. In basic research this means being able to financially support researchers fully so they don’t need to also rely on tradSci. In the aging/longevity field, this is happening quicker than expected. Three DeSci initiatives have emerged in the last year, VitaDAO, Impetus Grants, and Gitcoin that are funding in the $100K-$1M range. These funding levels are already about half of NIH’s shorter-term and longer-term grant mechanisms, R21 and R01, respectively. The goal for DeSci should be to continue to move from being a supplementary source of funding to being a main one.
2. Deprioritizing academic journals. DeSci funding organizations can help the researchers more than just with money. They can help scientists save considerable time. How? The simplest but biggest first step would be to make sure researchers interested in getting DeSci funding need only to have their research posted on preprint servers (e.g., BioRxiv, MedRxiv, and Arxiv) rather than also at academic journals like Nature, Science, and Cell. Why would DeSci funding agencies do this? It’s because academic journals waste huge amounts of researchers’ time on things that have little impact on the research. Things like having researchers format and reformat their work many times and respond to endless reviewer comments. Often it takes years to move from initial submission to the public release of the work in an academic journal. Also, academic journals profit disportionately off of the work of researchers because we not only produce the research and pay the journal to publish it, but we also review others’ work for the journal for free! If a preprint only requirement was made, researchers could post their results free of cost and with little time investment and move on to do more science. (TradSci grant agencies also waste huge amounts of researchers time, but until DeSci has enough money flowing through it researchers will still need to rely on it.)
Both clinical medicine and basic research will require strong coordination between DeSci organizations. DeFi applications seamlessly integrate with each other because they share the same database, the blockchain. The same needs to happen with DeSci. We need coordination between multiple DAOs to forge this new system independent of the tradSci oligarchy. As noted above, as soon as researchers can get their entire money from crypto, they won’t need the legacy system. One early example of inter-DAO coordination is LabDAO performing de-risking drug mechanism-of-action studies for the longevity therapies VitaDAO funded. These two organizations can trade tokens rather than transact in USD, saving both parties money while at the same time generating upside for each other.
How does Innovation happen?
Zooming out, let’s remember innovation doesn’t typically involve incumbents. Incumbents slow down the disruptor. Look at the handling of crypto by the SEC. The SEC held up crypto projects for years, played favorites, and won’t disclose its employees’ own crypto holdings. Fortunately, crypto pioneers have ignored the SEC’s indecision and bad faith negotiation and created ecosystems such as DeFi a $40B industry in less than two years (which rivals the budget that it took 80 years for NIH to have). We propose the same thing needs to happen with DeSci. Instead of waiting on the FDA, NIH, or anyone else to bless DeSci, crypto pioneers should just make it happen without the US.
DISCLAIMER: This is an opinion piece that represents the views of the author, Tim Peterson, and not those of VitaDAO.