Saturday, October 10, 2009

"Decline Is A Choice." So is A Serious Medicine Strategy.

Charles Krauthammer
declares that history “is in our hands.” Of course. But in the future, perhaps we can do a better job of shaping history than we have in the past. Perhaps, for example, we can create, with our own hands, a strategy for victory over illness, incapacitation, and death. And the latest encouraging news on a controversial topic, stem cell research, is yet another reminder that medical science can flourish only in a climate of political and cultural acceptance.

Krauthammer’s essay, “Decline Is a Choice,” delivered as the Wriston Lecture at the Manhattan Institute earlier this month, provides a broad framework to consider how ideas and politics set the stage for events, including scientific events. Krauthammer’s words are a reminder that we do, indeed, have power within our hands, individually and collectively--for better and for worse. His argument, that America’s leaders are choosing national decline, will hardly go unrebutted, but he is correct in his diagnosis of the dynamic: We can choose to decline, or we can choose to rise.

The same holds true for medical research. We can choose to have less medical research, or we can choose to have more. But either way, we should know that medical research is within our hands, even if we ourselves are not scientists. Why? Because like every other human endeavor, medical research occurs within politics, within a political framework. Aristotle was right, we are political beings. And Clausewitz, taking a page from Aristotle by way of Machiavelli, reminded us that war, too, occurs within politics. As Clausewitz so famously said, war is also just another kind of politics.

Clausewitz’s wisdom might be too bleak for some, in its Teutonic transactional reductionism, but the Clausewitzian point about war is even more powerful when applied to medicine: Since our instinctive human empathy for the sick does not apply to the dangerous agents of sickness--does not apply to the bacteria, viruses, chromosomal abnormalities, and toxins that accumulate in old age--we can afford to be unsentimental, even ruthless, in our anti-disease efforts. We can, as Jim Woodhill was the first to say to me, “fight a real war against disease.” A savage war of health, with apologies to Rudyard Kipling.

The implications of this Clausewitzian framework are profound. What we do is a function of our minds and personalities and the structures we create: our leadership, our herd instinct, our voluntary transactions, our involuntary transactions. And the scientific search for medical cures is just one subset of that human whole.

But is it really true that destiny is in our hands? That history is what we make of it? Through most of human existence, most people have said “no.” They have said that history is ordained by God, or by fate, or by irony--or by economics, religion, science, even ethnicity. But science, to apply a current voguish phrase from the healthcare debate, has always demonstrated its ability to “bend the curve,” either up, down, or in some new shape altogether.

Back in the third century BCE, Archimedes was one of the first to glimpse the plasticity of possibility: “Give me a place to stand on,” he thundered, “and I will move the earth.” Now that’s leverage--not only on the physical world, but also on the human mind. Gathering force ever since (albeit it with long lulls, as in the Dark Ages), human action has transformed human understanding, as well as our physical environment.

And since the Scientific Revolution, since the Enlightenment, and since the Industrial Revolution, a more anthropogenic theory of historical causation has come to dominate in the political realm. There is no ordained order, there is no great chain of being. We are the captains of our own outcomes. History is in our hands, and so is our civilization.

Thus science has been a big winner in the last few centuries, because the power to palpably change the world is seductive, indeed. As Alfred North Whitehead observed, the greatest invention of the 19th century was the idea of the invention--that is, the mostly German concept of creating research institutes where valid discoveries were cranked out on a veritable assembly line of knowledge.

Such rationalization of scientific charisma--the enduring synthesis of public, private, and civic--has been a spectacular success: In the area of medical science, thousands of good discoveries, millions of good practices, and billions of good decisions have served to more than triple American life expectancy over the last two centuries, from around 25 years to nearly 80.

So today we can ask ourselves: Do we want life expectancy to go higher still? Do we want infant mortality to fall further? Do we want to extend not only life, but productive life? As Krauthammer would say, it’s in our hands.

Therefore it’s useful to pause over his essay, now also the cover storyin new issue of The Weekly Standard. His chosen topic is foreign policy, and not everyone will agree with his prescriptions, but he is always interesting and entertaining:

"My thesis is simple: The question of whether America is in decline cannot be answered yes or no. There is no yes or no. Both answers are wrong, because the assumption that somehow there exists some predetermined inevitable trajectory, the result of uncontrollable external forces, is wrong. Nothing is inevitable. Nothing is written. For America today, decline is not a condition. Decline is a choice. Two decades into the unipolar world that came about with the fall of the Soviet Union, America is in the position of deciding whether to abdicate or retain its dominance. Decline--or continued ascendancy--is in our hands."

The key words in that paragraph are “in our hands.”

This “positive” view of American history--that we are the arbiters, that we can make things anew--has become such a commonplace that our politicians have forever been proclaiming a New Freedom, a New Deal, a New Frontier, a New Federalism, a New World Order, a New Economy. And as often as not, those “news” really are new, because we do have that sort of power--as Ronald Reagan liked to say, the power to begin the world over again.

Thus Barack Obama was standing on well-trod ground when he said during the 2008 presidential campaign: “We are the ones we've been waiting for. We are the change that we seek.”

Indeed. The lesson for Serious Medicine Strategists is that we can have a world-beating medical research enterprise for the 21st century if we want one. But we won’t have such an enterprise if we don’t want one.

In the meantime, we need to be alert to the opportunity to fit every piece of medical news, good and bad, into the overall theory of Serious Medicine. Why? Because to be persuasive, the theory of Serious Medicine must take into account current facts, must be grounded in history, must point constructively into the future. And that’s where Clausewitz comes in, because he so clearly focused his readers on the choices they faced--and the decisions they had to make, if they desired a victorious outcome.

So today, Neo-Clausewitzians speak of an ordered hierarchy that makes for military effectiveness: doctrine, strategy, tactics. At all times, there must be a functional relationship between the grand strategist and the grunt; a chain of command, a chain of being.

Each element in what might thus be called thought of a cone, or a column, logically linked and synced, piled on top of each other like building blocks, or a grand arch, for the effort to succeed. And that effort, Clausewitz further argued, is much bigger than just the military. The true effort is not just men at arms, as important as they are; the true effort, instead, is the nation as a whole--what it is willing and able to do.

But of course, this is the cyber age, and so a phrase more apt than "Clausewitzian Cone" or "Column" is needed. In the spirit of the cyber age, when the Internet, and, more broadly, information surrounds us, in ambient neo-Platonism, we might better think about the "Clausewitzian Cloud," as in cloud computing.

As our name suggests, here at Serious Medicine Strategy we believe in harnessing all available resources. So the Clausewitzian Cloud can be used as just another tool, a way of perceiving the comprehensive strategy needed to be applied to science and medical research.

Let’s consider the three elements:

*Do we have a doctrine (some might prefer the word “vision”) of medical research? Have we made, for example, a national determination to help people live longer--and perhaps to help them work happily and healthily for additional five or ten years?

*Do we have a strategy? Do we have, for example, a strategy for mobilizing public, private, and philanthropic dollars into the new mission? Are we willing to change intellectual property and tort laws to make way for the new strategy?

*Do we have tactics? Do we have, for example, the needed scientists and doctors to carry out our vision? And are disease activists, and other civic players, all on board?

And is each element fitted together, into what might be called a Clausewitzian Medical Cloud, so that the entire nation is productively mobilized on behalf of the Serious Medicine Strategy?

Such questioning might seem to be an over-elaboration of the obvious, but in fact, history shows that it is not so easy to maintain a sustained effort. If war was easy, Clausewitz wouldn’t have had to write his book. And if other kinds of national effort, including medical research, were easy, a lot more would have gotten done.

For one relatively brief shining moment, America concentrated on a dread disease, polio--and we made it go away in less than two decades. In 1938, President Roosevelt established the National Foundation for Infantile Paralysis, a.k.a. the March of Dimes. And seventeen years later, in 1955, we had the Salk Vaccine. Was it really that simple? No, of course not. That’s the Clausewitzian point. Such a victory comes only from the proper alignment of vision, strategy, and tactics. Amidst other challenges, FDR mobilized the nation and won a great victory over human suffering. There are many reasons why he is ranked among our greatest presidents.

By contrast, other “wars” against disease, less well handled, have taken much longer. Consider the slow struggle against smallpox. Observers had noticed the negative correlation between cowpox and smallpox since the Middle Ages--if you got one disease you didn’t get the other--but it was not until 1796 that an Englishman, Edward Jenner, had the idea of turning the mild cowpox into a vaccine against the deadly smallpox. And even then, it took 183 years for smallpox to be eradicated completely. Let’s give full credit to those at the Centers for Disease Control and the World Health Organization, who finally got the job done in 1979, but let’s also note that hundreds of millions of people died, and many more were disfigured, as leaders, worldwide, pursued other priorities.

So the sustained effort needed to keep the cures coming is greater than commonly understood. If the political class, reflecting an alert public, is closely monitoring medical progress, as it was during, say, the battle against polio--or as it was during the battle against HIV/AIDS in the 80s and 90s--then great progress is possible. But if leaders wander into other issues, however worthy those other issues might be, then medical progress will stagnate.

Today, for example, the big push coming out of Washington is “health insurance reform”; the primacy of medical research has been pushed aside by new claimants to primacy: social justice, financialization, and the free market. Each of those three new claimants might be perfectly meritorious, but if any of them come first, then medical research is likely to come second. Which, of course, underscores the basic Krauthammer point: History is in our hands. What we do makes all the difference.

A case in point is the latest news about stem cell research. As The Los Angeles Times explained, “Scientists are a big step closer to their long-term of goal of creating patient-specific stem cells that are safe to use and don’t require the destruction of embryos.” If so, if “induced pluripotent stem cells” prove to be effective, that would be the winningest of win-wins: better health with no ethical controversy.

If there is ever to be a Serious Medicine Strategy, it will come into being not only because scientists are free to make discoveries and develop cures, but because the political economy is ordered such that cures can be tested, judged, and mass-produced. Moreover, the cure-makers must be protected from over-eager regulators, economic rent-seekers, and, of course, trial lawyers. If not, the system will slow down, even break down.

The Clausewitzian Medical Cloud of vision, strategy, and tactics needs to be both ratified and also reified. Otherwise we will all end up being defeated by the diseases we have long fought.

There will be plenty of occasion in the future for filling in the details of a Clausewitz-inspired Serious Medicine Strategy. The purpose of this post is to help think through the basic idea, that Clausewitzian wisdom can, in fact, be transferred from military strategy to medical strategy.

Even his foes will have to agree that Krauthammer is correct in his overall frameworking: much power “is in our hands.” Decline is, indeed a choice--a choice that people make sometimes, although, more often, decline is the condition that systems naturally drift into. Entropy is easy.

By contrast, the opposite of decline--renewal and renaissance--is a genuine challenge. But we need a strategy for getting there. A Serious Medicine Strategy.

Mistakes will always be made, tragedies will still befall us, and Armageddon may come, but for now, we are sure: On this earth, the principal agent isn't Providence, or luck. The agent of change is us.


  1. History is ordained by politicians regardless of the electorate's wishes because the politicians only listen to money men, the men of power who bend curves as they damn well please.
    Nothing is in our hands; it is an illusion if we think otherwise.
    History wasn't in our hands when Lincoln was assassinated?
    Presently, and for quite some time, there has been a dysfunctional relationship between the "grand strategist" and the "grunt" or as I like to say, between the "Hill People" and "We the People."
    Per Clausewitz, war is nothing but a duel. I think that duel is over for Health Care and the Politicians have won. This 'Political Class' are like swine feeding at the troughs of corruption.
    The question is, 'is America in decline'? Well if the first two words of the Health Care Bill start with "Losers Pay" then I would say 'NO, America isn't in decline'.
    In todays Secular Society there is no such word as Reform because reform implies morality and justice. And the "Hill People" don't have morality. Hey, just ask their girl friends or lobbyists? Go Rangle or Geitner with that idea!
    Your basic idea "that Clausewitzian wisdom can, in fact, be transferred from military strategy to medical strategy" would be possible except for the fact that war is just an extension of politics and the Hill People really are corrupt bastards.
    Power is not in our hands Jim. Why hell, how many of us "We the People" vote?
    Want "A Serious Medicine Strategy" then get out the vote!
    The agent of change may be the politicians' realization that we will vote their behinds off of the Hill.
    Really want good Health Care reform? Then this Grandpa proposes we elect 535 grandmothers to the Hill, .... so long as they DON'T HAVE LAW DEGREES! Funny idea? Yea, but it would work wouldn't it? This idea of mine is better than 2 or 3 generals retiring because of Obama's Afghanistan position and our armies standing down in disgust in their barracks. There are many ways to reform Health Care, revolution could be one of them! I would like it if Thomas Jefferson could speak to us.
    A very, very thoughtful and noble piece Jim, thank you for your great efforts on this vital subject of Health Care. I hope and pray God you are right.

  2. Mr.Pinkerton: Of course I fully agree that if the ultimate bill does not have any semblance of a trigger or minor public option, the extenuating and evolving benefit that you outlined in your article will progress. If the tenets of our American medical system remain focused toward medical research and are not hindered by bean counting then maybe if Christopher Reeves had lived another 15 years, they could have opened a silo at Genentech or Amgen and fitted him with a transplanted spine.With Socialized Medicine ever evolving in our Democracy I see people waiting around armories and lucky to get a PSA test let alone any credible strides in research. As a fatalist and a pragmatist combined I do not see how anybody is going to be able to send Obama and Pelosi into a corner with a dunce cap on.I envisualize some form of public option and the thought something similar to tax avoidance which is perfectly legal as shrewd Americans will get the health care they need and desire at any cost.