Earlier today Jacoba Urist wrote an article in The Atlantic entitled More Money Won’t Win the War on Cancer. In my mind, she wrote a very compelling piece, with one small exception: I think she got part of the conclusion basically wrong.
First I have to get off my chest that I really don’t like the title and it’s reference to “winning” a “war” on cancer. I never liked the idea of a war on cancer, if only because it implies at its heart that there may come a time when we can plant the flag, declare victory, and go home. I don’t think it will ever be thus. And that means than anything less is like “losing” a war and I don’t think highly of that notion either. I wrote previously about the importance of words in dealing with cancer.
However, that’s just a personal soapbox issue I needed to get out of the way.
My main point in rebuttal of the main tenet of the article can best be framed by looking at the subtitle of the piece: A broken grant structure, turf wars, and an exodus of scientists for other professions are bigger barriers to progress than a lack of funding.
I agree with all the maladies she listed, and I won’t bother trying to expand on them all here. The original article is a good read and I encourage you to look at it. It gets all of the symptoms right. But in the end I think that these barriers are as much CREATED BY insufficient funding rather than stand-alone problems.
There is no doubt that most granting systems are broken – they do create a protracted process, they do tend to be risk averse and they do not often reward innovation and creativity, and above all, risk-taking, upfront. And as I myself wrote just last week, there is also a huge and growing over-attention to the notion of return on investment (ROI) that has seen a recent shying away from basic, fundamental knowledge-gathering kinds of cancer (and other) research).
A lot of the premise of the article is based on the thoughts of Clifton Leaf, who has many provocative, but very thoughtful ideas about what is wrong with the cancer research “system”. For the record, I am NOT attacking Mr. Leaf or his ideas here either.
But take this passage, for example:
Forty-two years after President Nixon signed the National Cancer Act and declared the “war on cancer,” it’s virtually impossible to separate cancer from money—walks, bike rides and pink ribbons entice people to donate more and more. To question the need for more funding to help cancer patients seems almost sacrilege.
But that is what Clifton Leaf, a cancer survivor (diagnosed with Hodgkin’s lymphoma in high school) and an editor at Fortune, asks in his book The Truth In Small Doses: Why We’re Losing The War on Cancer— and How to Win It: What if a lack of research funding isn’t really the problem? One reason we aren’t making faster progress against cancer, according to Leaf, is because the federal grant process often chases the brightest minds from academic labs, and for those who do stay, favors low-risk “little questions” over swinging for the fences.
“More money by itself is not going to solve anything,” Leaf said.
So, let’s just look at this a bit more closely. It is my belief that an awful lot of what is wrong with the research enterprise (i.e. the very things he lists) STEM from the fact that there is not enough money in the system overall.
Why do I say this, and what are my credentials for that observation? I was the head of the National Cancer Institute of Canada for many years and was the first Vice-President of Research for the Canadian Cancer Society. As such I was responsible, in one form or another, for the grant-making and peer review processes/systems of what was Canada’s largest national charitable funder of cancer research. Over 20 years at the helm of the peer review and granting processes, I too came to be frustrated by, and appreciated very much, most of the laments that Ms. Urist and Mr. Leaf make.
Why indeed do we seem to favour lower risk, (often called “incremental”) projects? Why do we want to hit singles instead of home runs? There is no doubt in my mind from personal observation of two decades, that when money for research gets tight, peer reviewers get increasingly risk-averse. That might be exactly the time when you WANT to swing for the fences, but it just never seems to work that way.
Think of it in terms of a personal investment portfolio. Most of us will want to see a balance between blue chip stocks, or dividend-bearing stocks, or even fixed-income vehicles to make sure our capital is safe. But if we have enough money, many would love to have a bit of risk capital or venture capital. Money that you are OK to lose, but money that you hope will win big.
So, if you suddenly fall on hard times and have to reduce your portfolio, where is the average person going to cut? Most likely the risky stuff, not the blue-chips.
And so it is with research. As soon as money gets tight, we become very risk averse – ironically at the very time when we ought not.
We make the rules tighter to make sure that we are only giving the money to the VERY best qualified, and often that means a protracted and increasingly cumbersome granting process. And we indirectly promote turf wars, as much between the really established scientists with great track records and those earlier in their careers who will move on to other pastures if they can’t get a foot in the funding door.
And then we wonder why our best scientists spend half of their time writing grant applications. And don’t forget the huge time burden of reading and reviewing each other’s grant applications as well!
If we really want to promote innovation and accept more risk in relation to the reward, and if we want to fix the granting system and get our scientists back into the research environment and out of the office where they read and write grants, then I believe we need to adopt a mantra of: Time, Freedom. Money. But unlike the old business saw of “Do you want it fast, cheap or good? Pick two”, we need to have all three in some balance…
We need to lengthen the time horizons over which we expect meaningful results. We have to give exceptional and creative scientists more rein to follow their noses. And we need more money, which is the glue that makes the other two possible.
So, do I agree that just throwing money at the problem will not solve it? I surely do agree. Will there ever be enough money? Nope.
But I also think that we will not achieve the cultural shifts we seek unless there is more freedom in the research system, and that freedom can only come with a more relaxed approach to funding and more dollars.
Mr. Leaf and Ms. Urist are unquestionably right in the assertion that money alone will NOT fix all these things. I could not agree more. But the things that CAN and DO need to be fixed are not going to fall easily unless there is more money to enable that cultural and system transition.
What I fear most from an article with a title like “More Money Won’t Win the War on Cancer” is that a critical nuance gets lost.
It is true that money alone cannot fix things, but for the public (whether as taxpayers or donors) to infer the opposite, namely that this means there is ENOUGH money in the research enterprise would be wrong, and would do us all a grievous disservice.