TL;DR: Healthcare practice, research and financing are organically intolerant towards innovation - even when it’s high-benefit and low-risk.

A horrible situation

A few years ago, one of my dear friends discovered that his child is suffering from a rare genetic disease that is likely to make the child blind within about 10 years.

As he overcame his own grief and dived into the rabbit hole of researching that disease, he discovered that all of the building blocks necessary for treating the disease in question are already in existence. However, he could not find anybody actually going for a cure. Why?

Domain experts agree that the project is quite approachable - similar conditions are getting cures through a number of robust strategies. Once a cure exists, it would save societies around the world billions in care for life-long blindness. Developing a treatment is surely a right and noble thing to do.

However, there are two interconnected problems that kill most projects of that kind -

  1. There is no class of people who are considered fit to lead such projects,
  2. There’s no class of institutions that routinely consider financing such projects.

The rest of the post attempts to explain why that is the case.

A project to propose and get regulatory approval for a treatment is a task that requires orchestrating several dozens of participants who mostly come from a broadly similar life-science background, but are all highly specialized in one of the necessary niches - these might include drug delivery, physiologists, animal lab personnel, pathologists, medical patent lawyers, medical statisticians, clinical research coordinators, and so on. While costs of development could run into tens of millions of US dollars, a shoestring seed budget of as little as 1 million could remove much uncertainity, especially if applied at scale.

Let’s go over who could orchestrate such a thing, and in what setting.

People: MDs; institutions: Healthcare/Hospital Systems

One obvious category of potential leaders is medical doctors, who serve as the organizational backbone of healthcare systems.

However, healthcare systems are at their core highly specialized operations businesses - they are therefore deeply intolerant of anything resembling R&D, with its inherent risk and its thirst for dynamic, business-competent leadership, and indeed the kind of flexibility that is required for business transformation.

Yes, medical school supplies individuals with more-than-sufficient knowledge, but the system will have them practice as individual contributors until they’re 45, at which point most will have lost the desire to innovate.

Probably the greatest exception to the above rule are MD track dropouts; the same applies to DVMs, and the rarer DMDs. For quite a few of them, the process of finding a new vocation teaches them how to find their inner voice - a qualifying skill for entrepreneurship.

A non-example is MD-PhDs. They actually do better than “regular MDs” in being exposed to advanced research techniques, but their arduous track means they need to spend most of their energy just to remain relevant as individual contributors - a soul-crushing drag for an entrepreneur.

People: scientists; institutions: academia

The second category of potential leaders is scientists, who are the backbone of the world’s various academic institutions. However, the entirety of the academic track incentivizes an exclusive focus on small incremental advancements attributable to a scientist’s original work - this is wildly different from delivering a cure to a disease, which is a holistic problem requiring multiple collaborators, many of whom do not do anything particularly original.

Moreover, it makes sense for researchers to select their research areas so that they’ll get funding – which typically means, politically aligning with the senior scientists that grant them funds. However it also means that areas that for whatever reasons are out of tune with respect to the current consensus are considered hazard zones; going there is tantamount to career suicide. Since there’s typically very little publication value in bringing a cure to the market, it is not worth any career minded researcher’s time.

People: scientists; institutions: pharma

Most graduates leave academia, not a few due to the futility of the approach described in the previous section. The pharmaceutical industry is a natural rallying ground for academic leavers with a life science background.

An outsider might be tempted to think this nails it - here are people and organizations ostensibly incentivized to improve medical treatments. However insiders know that this is by-and-large not the case.

Indeed, practically, pharmaceutical companies devote the vast majority of their resources towards making minor improvements to existing treatments as opposed to developing major new ones. This preference connects organically to organizational cultures that are predominantly risk-averse. By the time most individuals reach a position of influence inside a pharma company, they have been selected for yielding to the consensus – hardly the mindset for disruption.

The conclusion

With nobody else even remotely relevant, my friend took upon himself to be the person bringing about the cure – so far with remarkable results. There are some signs that he’s going to make it. I keep my fingers crossed for him, and I’m proud as hell to have such a friend.

The good news is that in spite of the system being badly broken, there are some capable people out there. In particular, there’s a certain type of hungry-eyed outcasts who have somehow managed to avoid the brain rot described above and remain competent as practitioners, and credible as leaders.

A converse of the above is being wary of traditionally successful academics. Entrepreneurship often requires tuning into other people’s vision and obsessing over process quality; both are antithetical to shining in academia.

I wanted to conclude with a note of hope: we live in a time of miracles. Let’s try to hang on and be kinder to each other, and perhaps one day things will be somewhat easier.