WEBVTT 1 00:00:00.330 --> 00:00:08.380 Decentralized Institutes of Health Your military-industrial complex solved coordination for killing: weapons manufacturers, 2 00:00:08.580 --> 00:00:13.840 generals, politicians, and factory workers all profit from the same budget, so they all show up. 3 00:00:14.820 --> 00:00:19.980 Disease has no such coalition. Your Decentralized Institutes of Health builds one. 4 00:00:20.500 --> 00:00:28.620 It does three things: receive treaty funds, allocate them via patient choice and wishocratic voting, and pay based on results 5 00:00:28.620 --> 00:00:36.420 instead of grant applications. It's the Supreme Headquarters Allied Expeditionary Force, or SHAEF, for the war on disease. 6 00:00:37.140 --> 00:00:42.380 Same selfishness as the military-industrial complex, but pointed at biology instead of each other. 7 00:00:43.040 --> 00:00:47.140 Nobody gets paid for writing essays about why they should be allowed to try curing things. 8 00:00:47.900 --> 00:00:56.020 They get paid for curing things. I have been watching your species fight disease for eighty years, and I want to describe 9 00:00:56.020 --> 00:01:01.640 what I see, because I think if you saw it from the outside you would be embarrassed. 10 00:01:02.320 --> 00:01:06.280 You have eight billion of people humans. Some of them are sick. 11 00:01:06.760 --> 00:01:13.150 Some of them are scientists who could help the sick ones. And some of them are sitting in offices writing forty-seven-page 12 00:01:13.760 --> 00:01:21.040 documents explaining why they should be allowed to try. These documents are called "grant applications." 13 00:01:21.360 --> 00:01:29.240 They take six months to write and forty minutes to reject. Your scientists spend fifty to sixty-seven percent of their time 14 00:01:29.240 --> 00:01:36.320 writing them. The other thirty-three to fifty percent is spent doing science, which is the thing they were hired for, though 15 00:01:36.320 --> 00:01:40.380 at this point it's more of a hobby they squeeze in between grant applications. 16 00:01:41.120 --> 00:01:48.140 I asked one of your scientists what a grant application is and she said "it's a document where you explain what you'd discover 17 00:01:48.140 --> 00:01:53.300 if someone let you." Which means your scientists already know what they'd find. 18 00:01:53.440 --> 00:02:00.760 So why do they need the money? I thought about this for a long time and then I realized I'd misunderstood the question, 19 00:02:01.260 --> 00:02:05.660 which is also what happens to most grant applications. Your N.I.H. 20 00:02:05.740 --> 00:02:12.640 spends forty-seven billion dollars a year. Billions flow to projects that never produce treatments. 21 00:02:13.080 --> 00:02:21.460 Your system isn't designed to cure disease. It's designed to produce grant applications, which occasionally, as a side effect, 22 00:02:21.900 --> 00:02:27.420 produce medicine. This is like designing a restaurant whose primary output is menus. 23 00:02:28.080 --> 00:02:32.580 Sometimes, by accident, food comes out. Everyone acts surprised when it does. 24 00:02:33.300 --> 00:02:39.040 This is not a conspiracy. It's just what happens when you pay people for asking instead of finding. 25 00:02:39.480 --> 00:02:47.100 You've built a machine whose primary output is requests for money and whose secondary output is, reluctantly, science. 26 00:02:47.740 --> 00:02:53.140 On Wishonia, we have a word for systems that produce the opposite of their stated purpose. 27 00:02:53.420 --> 00:03:01.580 The word is "human." We also use it as a verb. As in, "the project was going well until someone humaned it.". 28 00:03:01.940 --> 00:03:07.220 Your Decentralized Institutes of Health is what you'd build if you started over and actually meant it. 29 00:03:07.760 --> 00:03:13.810 Here's the blueprint. The Health-Industrial Complex: Coordinating Your War on Disease. 30 00:03:14.380 --> 00:03:23.780 The Olsonian Problem. Your economist Mancur Olson identified why public goods are systematically underproduced: diffuse 31 00:03:23.780 --> 00:03:32.320 benefits and concentrated costs. In simpler terms: everyone benefits from a cure for cancer, but nobody benefits enough 32 00:03:32.320 --> 00:03:36.640 to fight for it the way a weapons manufacturer fights for a bomber contract. 33 00:03:37.340 --> 00:03:45.020 It's one of those observations that's obvious once someone says it, and invisible before, which describes most of your species' 34 00:03:45.160 --> 00:03:49.540 problems. Curing cancer benefits eight billion people a little. 35 00:03:50.000 --> 00:03:57.240 But nobody benefits enough to organize, lobby, and fight for it the way a defense contractor fights for a bomber contract. 36 00:03:57.760 --> 00:04:05.240 The eight billion don't show up. This is why your species has spent fifty years "fighting cancer" while your defense industry 37 00:04:05.240 --> 00:04:11.020 got stealth bombers, aircraft carriers, and G.P.S. The defense industry showed up. 38 00:04:11.840 --> 00:04:17.980 Cancer patients were busy having cancer, which is time-consuming in a way that's hard to explain to people who haven't tried 39 00:04:17.980 --> 00:04:25.360 it, and which I understand is not recommended. Your military-industrial complex solved this problem for killing. 40 00:04:25.920 --> 00:04:33.580 Weapons manufacturers, generals, politicians, and factory workers all have concentrated interests in military spending. 41 00:04:33.940 --> 00:04:42.780 They coordinate. They lobby. They win budgets. Result: the most sophisticated death-delivery infrastructure in human history. 42 00:04:43.360 --> 00:04:50.740 Also result: the most sophisticated death-delivery infrastructure in human history pointed at everyone, including the people 43 00:04:50.740 --> 00:04:58.160 who paid for it. I looked up "death-delivery" and it's not a real phrase, but it should be, because your species has been 44 00:04:58.160 --> 00:05:05.380 doing it professionally since before you had writing, which means you were killing each other before you could spell "killing," 45 00:05:05.740 --> 00:05:09.840 which takes some commitment. Disease has no such coalition. 46 00:05:10.360 --> 00:05:14.940 Your patients are too sick to lobby. Your researchers compete for scraps. 47 00:05:15.200 --> 00:05:22.680 Your funders lack coordination. Your politicians get no credit for cures that arrive after their term ends (which is all 48 00:05:22.680 --> 00:05:29.880 of them, because cures take fifteen years and terms last four, which is a scheduling problem your species has never solved 49 00:05:29.880 --> 00:05:37.800 and never tried to). Everyone wants disease eradicated; no one has a concentrated interest in making it happen. 50 00:05:38.200 --> 00:05:44.960 It's like everyone wanting a clean kitchen but nobody wanting to do the dishes, except the dishes are cancer and the kitchen 51 00:05:44.960 --> 00:05:54.020 is on fire. Your Decentralized Institutes of Health will solve the Olsonian problem by creating concentrated interests in 52 00:05:54.020 --> 00:06:03.400 disease eradication. It will build a health-industrial complex that coordinates actors around eradication the way your military-industrial 53 00:06:03.400 --> 00:06:07.640 complex coordinates actors around making humans stop being alive. 54 00:06:08.600 --> 00:06:13.620 Same structure, opposite purpose. Same selfishness, better direction. 55 00:06:13.920 --> 00:06:21.280 Supreme Headquarters Allied Expeditionary Force, or S.H.A.E.F., for Your War on Disease. 56 00:06:21.500 --> 00:06:25.360 In nineteen forty-four, Eisenhower didn't replace the Allied armies. 57 00:06:25.580 --> 00:06:32.180 He coordinated them. Set the objective, allocated resources, made sure everyone pulled in the same direction. 58 00:06:32.700 --> 00:06:38.420 Your Decentralized Institutes of Health will be S.H.A.E.F. for the war on disease. 59 00:06:39.160 --> 00:06:43.360 Pharma companies stay pharma companies. Universities stay universities. 60 00:06:43.840 --> 00:06:51.520 Patient groups stay patient groups. But they operate as one force because the coordination layer points them at the same 61 00:06:51.520 --> 00:06:58.440 thing, which is the thing they were all supposedly pointed at already, except they weren't, because nobody was coordinating. 62 00:06:58.760 --> 00:07:04.060 Your war on disease has been losing for fifty years because it's not actually a war. 63 00:07:04.480 --> 00:07:11.700 It's a collection of uncoordinated skirmishes where researchers compete for grants, pharma companies hide failures, and 64 00:07:11.700 --> 00:07:21.340 patients can't access trials. You've been "fighting" cancer the way a cat "fights" a laser pointer: lots of energy, no coordination, 65 00:07:21.720 --> 00:07:29.210 nothing caught. Imagine if D-Day had been run this way. The Americans land at one beach, the British at another. 66 00:07:29.460 --> 00:07:35.500 Neither tells the other what they learned. Both compete for the same supply ships while the enemy reads their grant applications. 67 00:07:37.220 --> 00:07:44.160 This is how your species currently runs medical research, and you've been doing it long enough that it feels normal, which 68 00:07:44.160 --> 00:07:49.260 is the most dangerous thing about it. The R.O.I. Maximization Protocol. 69 00:07:50.580 --> 00:07:54.860 Your Decentralized Institutes of Health will not be a platform. 70 00:07:55.300 --> 00:07:58.460 It won't be an organization. It won't even really be a thing. 71 00:07:59.320 --> 00:08:04.780 It will be a coordination protocol, which means it's the rules by which the things talk to each other. 72 00:08:05.700 --> 00:08:10.880 On Wishonia, we built ours four thousand two hundred and ninety-seven years ago. 73 00:08:11.560 --> 00:08:18.340 It does one thing: make every actor's most selfish choice also be the most useful choice. 74 00:08:19.160 --> 00:08:25.140 Every dollar flows to maximum impact. Every researcher works on the highest-value problem. 75 00:08:25.900 --> 00:08:30.560 Every patient joins the trial that matters most. Nothing gets wasted. 76 00:08:31.300 --> 00:08:36.600 On your planet, you call this radical. On mine, we call it "obvious." 77 00:08:37.059 --> 00:08:43.460 It's been running longer than most of your civilizations have existed, though to be fair that's a low bar given how often 78 00:08:43.460 --> 00:08:51.620 yours collapse. It will do exactly three things: Receive funds (from the one percent Treaty, donations, etc.). 79 00:08:52.440 --> 00:08:59.560 Allocate research via patient subsidies (a market mechanism where sick people choose which trials to join and the money 80 00:08:59.560 --> 00:09:06.140 follows them) and infrastructure via Wishocracy (where everyone votes on which buildings to build). 81 00:09:06.940 --> 00:09:14.180 Verify results and pay proportional to impact (the part where you only get money if something actually worked, which is 82 00:09:14.180 --> 00:09:20.520 apparently a novel concept in your research sector). Everything operational will be outsourced. 83 00:09:20.780 --> 00:09:24.840 Trial infrastructure? Existing and new providers will compete for the work. 84 00:09:25.700 --> 00:09:30.740 Task decomposition? A.I. services. Talent matching? Existing marketplaces. 85 00:09:31.480 --> 00:09:37.080 The protocol itself will do almost nothing, on purpose. Why stay thin? 86 00:09:37.760 --> 00:09:42.520 Because thin protocols are hard to capture. There will be nothing to bribe. 87 00:09:42.840 --> 00:09:47.280 No operational role to corrupt. No C.E.O. to take on a yacht trip. 88 00:09:47.840 --> 00:09:55.920 Just rules that move money toward measured outcomes. Your species has a habit of corrupting every institution you build. 89 00:09:56.540 --> 00:10:01.560 You corrupt them the way water corrodes pipes: inevitably, given enough time and contact. 90 00:10:02.360 --> 00:10:06.700 The solution is to make the pipe so small and boring that nobody bothers. 91 00:10:07.160 --> 00:10:15.040 This one is boring enough that nobody bothers. Pay for Results (A Concept Your Research Sector Has Somehow Avoided). 92 00:10:15.880 --> 00:10:23.280 Every dollar will flow based on results, not promises. Patients will vote with their enrollment, and researchers will get 93 00:10:23.280 --> 00:10:31.400 paid for attracting them. Outcomes will determine continued funding, so campaigns that deliver will get more and failures 94 00:10:31.400 --> 00:10:39.780 will get defunded. Nobody gets paid for writing grant proposals, attending review committees, or publishing papers about 95 00:10:39.780 --> 00:10:45.180 why their research might work someday. This is how most other industries work. 96 00:10:45.780 --> 00:10:50.500 You pay contractors when they build the house, not when they promise to build it. 97 00:10:50.740 --> 00:10:55.680 You pay farmers when they grow the food, not when they apply for a farming license. 98 00:10:56.500 --> 00:11:00.120 Medicine, for reasons nobody can explain, went the other way. 99 00:11:01.440 --> 00:11:07.860 Your Data Commons: Publish Everything. Your current system hides failures. 100 00:11:08.360 --> 00:11:13.140 Companies bury negative results. Researchers don't publish what didn't work. 101 00:11:13.840 --> 00:11:21.360 Your scientists waste billions repeating mistakes someone else already made because they literally cannot find out those 102 00:11:21.360 --> 00:11:28.520 mistakes were already made. It's like your whole species has amnesia, but only for the embarrassing parts. 103 00:11:29.060 --> 00:11:34.180 You remember your triumphs in high definition and forget your failures completely. 104 00:11:34.900 --> 00:11:39.200 This is called "being human." It's also called "why you keep dying.". 105 00:11:40.020 --> 00:11:48.140 Your Decentralized Institutes of Health will require one hundred percent open publication of all data, positive and negative, 106 00:11:48.640 --> 00:11:55.310 as a condition of funding. Every trial, every result, every dataset will be published. 107 00:11:55.440 --> 00:12:00.180 A.I. models will scan the global data commons, finding patterns humans miss. 108 00:12:00.940 --> 00:12:05.160 Failed experiments will become shared knowledge, not repeated waste. 109 00:12:06.140 --> 00:12:12.760 This is intelligence sharing in the Supreme Headquarters Allied Expeditionary Force, or S.H.A.E.F. 110 00:12:12.840 --> 00:12:18.340 analogy. Your Allies won partly because they shared Ultra intercepts across commands. 111 00:12:19.000 --> 00:12:23.600 Your war on disease loses because everyone guards their failures like trade secrets. 112 00:12:24.620 --> 00:12:32.000 It's a group chat where everyone shares what didn't work. Except the group is your entire species and the topic is death 113 00:12:32.000 --> 00:12:38.720 prevention, which you'd think would motivate sharing, but doesn't, because your scientists are more afraid of looking wrong 114 00:12:38.720 --> 00:12:45.980 than of people staying dead. Governance: Sick People Choose, Everyone Else Votes. 115 00:12:46.860 --> 00:12:54.000 Your Decentralized Institutes of Health will use two allocation mechanisms, because using one would be too simple and using 116 00:12:54.000 --> 00:13:00.340 three would be too complicated, and your species seems to operate best with exactly two of things. 117 00:13:00.380 --> 00:13:04.500 Two eyes, two hands, two political parties, two allocation mechanisms. 118 00:13:05.280 --> 00:13:09.320 Three confuses you. One bores you. Two is the human number. 119 00:13:09.940 --> 00:13:15.170 I don't know why. Maybe it's the eyes. Patient subsidies will handle research funding. 120 00:13:15.340 --> 00:13:20.000 Sick people will choose which trials to join. Money will follow their enrollment. 121 00:13:20.560 --> 00:13:27.040 This means research funding will be allocated by the people who will die if it doesn't work, which is a better selection 122 00:13:27.040 --> 00:13:30.680 mechanism than a committee of people who will not die either way. 123 00:13:31.460 --> 00:13:39.320 Subsidies will be weighted by disease burden (disability-adjusted life years, or D.A.L.Y.s per patient), so severe conditions 124 00:13:39.320 --> 00:13:47.450 pay more per enrollee and mild ones pay less, which means every dollar buys the most healthy life-years possible. 125 00:13:47.640 --> 00:13:51.080 No committee will sit around deciding "cancer vs. Alzheimer's." 126 00:13:51.380 --> 00:13:57.440 The patients will decide, by showing up, and the price signal will make sure the money goes where the suffering is. 127 00:13:58.460 --> 00:14:06.140 Wishocracy will handle infrastructure and public goods. It will aggregate preferences through pairwise comparisons ("electronic 128 00:14:06.140 --> 00:14:14.740 health record, or E.H.R. integration or security audits?"), which is a fancy way of saying it asks everyone which of two 129 00:14:14.740 --> 00:14:19.240 things matters more, over and over, until a ranking emerges. 130 00:14:19.960 --> 00:14:25.680 Your species already does this when choosing restaurants. You just hadn't applied it to anything important. 131 00:14:27.200 --> 00:14:34.200 Making Selfishness Cure Disease. Your Decentralized Institutes of Health won't rely on altruism. 132 00:14:34.740 --> 00:14:42.360 Altruism is lovely but flaky. It shows up when it feels like it, cancels last minute, and is always "busy that weekend." 133 00:14:42.900 --> 00:14:49.560 Instead, it will pay everyone to do the most useful thing, because greed is more dependable than kindness. 134 00:14:50.120 --> 00:14:55.660 Your entire economic system proves this daily. Nobody ever forgot to be greedy. 135 00:14:56.280 --> 00:14:59.900 Greed doesn't need a reminder app. It doesn't have a snooze button. 136 00:15:00.300 --> 00:15:05.920 It's the only human trait that works consistently, which is why it's the only one worth building on. 137 00:15:07.640 --> 00:15:14.480 Your researchers will get per-patient subsidies weighted by disease burden, so treating severe conditions will pay more 138 00:15:14.480 --> 00:15:22.140 than treating mild ones. Your patients will get their trial costs covered, so joining experimental treatments costs nothing 139 00:15:22.140 --> 00:15:29.100 instead of everything. Your funders will get quadratic matching and outcome tracking, so high-R.O.I. 140 00:15:29.460 --> 00:15:37.040 donations will be amplified. Your data providers will get fees tied to data utility, so more useful data will mean more 141 00:15:37.040 --> 00:15:44.040 revenue. Every single actor's most selfish choice will also be the most useful choice. 142 00:15:44.160 --> 00:15:51.580 Selfishness, properly directed, will cure cancer. The civilizations I've worked with that figured this out are still around. 143 00:15:51.940 --> 00:15:58.600 The ones that decided selfishness was the problem and tried to build systems that required everyone to be nice are not. 144 00:15:59.260 --> 00:16:06.660 I don't say this to be mean. I say it because the archaeological record is very clear, and the archaeological record does 145 00:16:06.660 --> 00:16:15.720 not have feelings. How Your Researchers Get Paid. Your traditional system works like this: write a grant proposal, hope 146 00:16:15.720 --> 00:16:22.020 a committee likes it, get paid to try, maybe produce results, maybe not, get paid either way. 147 00:16:22.520 --> 00:16:28.480 It's one of the few professions on your planet where not doing the thing you're paid for has no consequences. 148 00:16:29.500 --> 00:16:36.960 (Actually, I've since learned this describes most of your government agencies, except those tend to get paid more for actively 149 00:16:36.960 --> 00:16:40.520 doing the opposite of their stated purpose, which is at least ambitious.). 150 00:16:41.900 --> 00:16:50.040 The new system: per-patient subsidies weighted by disease burden, with one equation that replaces your entire grant committee 151 00:16:50.040 --> 00:17:00.020 apparatus: Where is the subsidy per patient enrolled in a trial for condition is the disability-adjusted life years, or 152 00:17:00.020 --> 00:17:07.900 D.A.L.Y.s per patient for that condition (from your W.H.O.'s Global Burden of Disease data, which already exists and nobody 153 00:17:07.900 --> 00:17:15.720 was using for this), and is the value per D.A.L.Y. (a single constant, tuned to exhaust the annual budget). 154 00:17:16.359 --> 00:17:23.460 That's it. That's the whole allocation mechanism. The more patients who join your trial and the more severe the condition, 155 00:17:23.640 --> 00:17:27.339 the more funding you'll get. Patients vote with their enrollment. 156 00:17:27.960 --> 00:17:32.700 The price signal ensures every dollar buys the most healthy life-years possible. 157 00:17:33.440 --> 00:17:41.060 Cost is handled automatically: if the subsidy exceeds trial cost per patient, the trial is profitable and researchers will 158 00:17:41.060 --> 00:17:48.760 run it. If trial cost exceeds the subsidy, nobody runs it, which is correct, because it means the health value doesn't justify 159 00:17:48.760 --> 00:17:57.260 the expense. Researchers who find cheaper ways to run trials pocket the difference, which incentivizes efficiency instead 160 00:17:57.260 --> 00:18:00.880 of the current system, which incentivizes asking for more money. 161 00:18:01.780 --> 00:18:08.700 The only thing set centrally is which is just division: budget divided by global disease burden. 162 00:18:09.380 --> 00:18:16.620 Everything else is decentralized. Your entire species has been running grant committees for decades when you could have 163 00:18:16.620 --> 00:18:21.720 been running one equation. On Wishonia, this discovery took us about forty minutes. 164 00:18:22.400 --> 00:18:26.440 Your species has been at it for seventy years, which is not forty minutes. 165 00:18:26.880 --> 00:18:35.140 I've checked. Results-based continuation: deliver results and get more funding, or don't deliver and get defunded, which 166 00:18:35.140 --> 00:18:40.360 is how every other job on your planet works except, somehow, research. 167 00:18:41.200 --> 00:18:48.380 Pay your scientists like you pay your plumbers: for fixing the problem, not for explaining why the problem is hard. 168 00:18:49.580 --> 00:18:55.940 How It Works For Your Patients. Your Decentralized Institutes of Health won't replace your healthcare system. 169 00:18:56.840 --> 00:19:00.340 It will add an experimental treatment insurance layer on top. 170 00:19:00.980 --> 00:19:06.660 Your species already understands insurance. I've been trying to understand insurance for forty years. 171 00:19:07.100 --> 00:19:14.220 As far as I can tell, it's a system where you pay money every month so that when something bad happens, a different person 172 00:19:14.220 --> 00:19:21.380 can explain to you, using very long words, why the bad thing that happened isn't the kind of bad thing they meant. 173 00:19:22.120 --> 00:19:27.670 It's like a promise, but with lawyers, which on your planet means it's the opposite of a promise. 174 00:19:27.880 --> 00:19:32.420 This is similar, except it works. Sarah has Type Two Diabetes. 175 00:19:32.780 --> 00:19:39.560 Metformin isn't working. Under the old system, she has no other options covered and pays hundreds per month for a branded 176 00:19:39.560 --> 00:19:46.000 drug that's performing about as well as the drug that isn't working, which is a choice between two kinds of not working, 177 00:19:46.480 --> 00:19:53.880 which her species calls "options." With your Decentralized Institutes of Health, her doctor checks the trial network during 178 00:19:53.880 --> 00:19:58.940 a regular visit. Sees relevant trials. Recommends one based on Sarah's profile. 179 00:19:59.240 --> 00:20:03.280 Sarah enrolls with one click. The trial coverage pool covers all costs. 180 00:20:03.600 --> 00:20:07.740 Sarah pays a small copay. Gets an experimental drug that might work better. 181 00:20:08.080 --> 00:20:11.560 Reports blood sugar via app. Her data helps the next patient. 182 00:20:12.060 --> 00:20:18.680 Total time added to doctor visit: three minutes. Total time spent not dying: potentially the rest of her life. 183 00:20:19.240 --> 00:20:25.480 The ratio between these numbers seems favorable. Your doctors will cooperate because they get more treatment options for 184 00:20:25.540 --> 00:20:31.180 desperate patients, no liability (covered by trial insurance), and minimal workflow changes. 185 00:20:31.540 --> 00:20:38.400 Your patients will use it because they get affordable access to experimental treatments, doctor-recommended, with insurance-like 186 00:20:38.400 --> 00:20:46.100 coverage and no financial risk. It's like being a guinea pig, except the guinea pig gets paid, gets medicine, and consented 187 00:20:46.100 --> 00:20:50.360 to the arrangement, which distinguishes it from all previous guinea pig situations. 188 00:20:51.380 --> 00:20:56.880 How the Money Flows. The Architecture. The one percent Treaty Fund will hold the treasury. 189 00:20:57.580 --> 00:21:03.760 Money will come in from the one percent Treaty. It will allocate between infrastructure and public goods via Wishocracy. 190 00:21:04.540 --> 00:21:12.100 It will fund campaigns, not bureaucracies. It will have no C.E.O., no board, and no one to corrupt, (which will make it 191 00:21:12.100 --> 00:21:15.800 the first financial institution in your history with that property). 192 00:21:16.500 --> 00:21:22.720 Your Decentralized Institutes of Health will be the thin coordination protocol that receives funding from the one percent 193 00:21:22.860 --> 00:21:28.600 Treaty Fund, allocates research via patient subsidies, verifies results, and pays for outcomes. 194 00:21:29.440 --> 00:21:33.060 It will be a set of rules, not a building. You won't visit it. 195 00:21:33.080 --> 00:21:36.580 You won't lobby it. You won't take it to lunch. This is the point. 196 00:21:37.440 --> 00:21:42.600 Trial infrastructure providers will be funded campaigns that compete to provide trial infrastructure. 197 00:21:43.160 --> 00:21:49.000 They won't be part of your Decentralized Institutes of Health; they'll be service providers with no budget authority, the 198 00:21:49.000 --> 00:21:54.620 same way a restaurant kitchen is not part of the building's plumbing even though they both involve pipes. 199 00:21:54.760 --> 00:22:02.700 The Fund Flow. Your one percent Treaty redirects twenty-seven point two billion dollars a year from global military budgets 200 00:22:02.700 --> 00:22:09.000 into the one percent Treaty Fund. Not all of it reaches research, because some of it goes to keeping the machine running, 201 00:22:09.040 --> 00:22:15.740 (which is how all machines work including your current ones, except this one admits it): Incentive Alignment Bonds receive 202 00:22:15.740 --> 00:22:23.800 ten percent plus ten percent, totaling two point seven two billion dollars plus two point seven two billion dollars, to 203 00:22:23.800 --> 00:22:32.300 align investors and politicians with outcomes. The research treasury receives eighty percent, totaling twenty-one point 204 00:22:32.300 --> 00:22:40.260 eight billion dollars, allocated via Wishocracy (approximately ninety-seven percent to disability-adjusted life years, or 205 00:22:40.260 --> 00:22:46.050 D.A.L.Y.-weighted patient subsidies, and approximately three percent to infrastructure). 206 00:22:46.300 --> 00:22:53.140 What Gets Funded: Market Failures Only. Most research allocation will happen automatically. 207 00:22:53.680 --> 00:23:00.180 Patients will choose trials, funding will flow there, and the market will handle it the way markets handle most things: 208 00:23:00.980 --> 00:23:08.800 imperfectly but vigorously. The one percent Treaty Fund will step in only for the things markets genuinely can't do. 209 00:23:09.960 --> 00:23:19.040 Infrastructure includes development and operations, competing alternative implementations, data commons storage and processing, 210 00:23:19.660 --> 00:23:24.320 security audits and fraud detection. These are the pipes and plumbing. 211 00:23:25.000 --> 00:23:30.300 Nobody builds pipes for fun. Markets don't produce pipes unless someone pays for them. 212 00:23:30.900 --> 00:23:39.540 So the fund pays for them. True public goods include patient trial participation subsidies, negative results publishing, 213 00:23:39.940 --> 00:23:47.740 and replication studies. These are the things nobody wants to pay for because the benefit is diffuse and the payer gets 214 00:23:47.740 --> 00:23:54.760 no credit. Your species has known about this problem since Olson described it, which was decades ago, and has done nothing 215 00:23:54.760 --> 00:24:00.640 about it, which is also decades ago. This is minimal by design. 216 00:24:00.780 --> 00:24:08.080 Your ecosystem will handle most research funding automatically: companies will register treatments, patients will join trials, 217 00:24:08.620 --> 00:24:16.660 revenue will flow, research will happen. Your Decentralized Institutes of Health will only direct the one percent Treaty 218 00:24:16.660 --> 00:24:23.920 Fund to cover what the market genuinely can't, which is less than you think, because markets are surprisingly competent 219 00:24:23.920 --> 00:24:27.560 when you let sick people choose where to spend money on not being sick. 220 00:24:28.780 --> 00:24:33.370 What Your Decentralized Institutes of Health Outsources (Everything). 221 00:24:34.620 --> 00:24:38.010 Your Decentralized Institutes of Health will be intentionally minimal. 222 00:24:38.740 --> 00:24:45.240 It will outsource everything operational because the best way to avoid corruption is to have nothing worth corrupting. 223 00:24:45.760 --> 00:24:50.990 If a provider stops performing, you'll fund a better one. This is how your species runs restaurants. 224 00:24:51.780 --> 00:25:00.140 Time to try it with medicine. Trial infrastructure will go to competing providers, because separate concerns stay uncorrupted. 225 00:25:01.080 --> 00:25:08.060 Crowdfunding will go to existing platforms, because they already exist and work (your species has already built functional 226 00:25:08.060 --> 00:25:11.940 crowdfunding; no need to reinvent it just because the cause is better). 227 00:25:12.940 --> 00:25:20.780 Talent matching will go to existing marketplaces. Data storage will go to competing providers, because market competition 228 00:25:20.780 --> 00:25:28.020 works better than monopoly, which you'd think would be obvious by now given that your entire economic philosophy is based 229 00:25:28.020 --> 00:25:31.580 on this observation and yet your government keeps forgetting it. 230 00:25:32.300 --> 00:25:42.340 Every outsourced function follows the same lifecycle: propose, vote via Wishocracy, receive funding, deliver, get measured, 231 00:25:42.660 --> 00:25:47.350 and earn continued funding based on results. This is called "accountability." 232 00:25:48.000 --> 00:25:55.380 Your species invented the word. I looked it up and it has existed in your language for over four hundred years. 233 00:25:55.980 --> 00:26:03.740 Time to try the concept. Anti-Capture Design. Your current system is trivially captured. 234 00:26:04.380 --> 00:26:09.140 Concentrate billions of dollars in a few committees, and lobbyists will find them. 235 00:26:09.860 --> 00:26:17.480 This is as predictable as gravity, and your species keeps being surprised by it, which is surprising, because the surprising 236 00:26:17.480 --> 00:26:24.260 thing is that you're surprised, which shouldn't be surprising because you've been surprised by it every time, which means 237 00:26:24.260 --> 00:26:29.700 being surprised is actually the normal thing, which means it's not surprising, which means... 238 00:26:30.700 --> 00:26:39.940 I've lost track. The point is lobbyists find money. They find it the way a dog finds a vacuum cleaner, except the dog runs 239 00:26:39.940 --> 00:26:48.580 away and the lobbyist runs toward it. Your Decentralized Institutes of Health will make capture economically irrational 240 00:26:48.580 --> 00:26:54.920 by removing everything worth capturing. There will be no C.E.O., so there will be nothing to bribe. 241 00:26:55.360 --> 00:27:03.280 Governance rules will be encoded in transparent, auditable systems, and you can't bribe an algorithm (several of your corporations 242 00:27:03.280 --> 00:27:10.800 have tried; the algorithm didn't notice). Every dollar will be tracked on a public ledger, so corruption will be visible 243 00:27:10.800 --> 00:27:18.660 to everyone with an internet connection. Anyone will be able to build a competing alternative, so capturing one will just 244 00:27:18.660 --> 00:27:26.880 trigger the creation of another. Millions will vote via Wishocracy, so lobbying won't scale (you can bribe a committee of 245 00:27:26.930 --> 00:27:34.560 twelve; you cannot bribe a committee of twelve million, or rather you can, but it's called "taxation" and requires winning 246 00:27:34.560 --> 00:27:42.040 an election first). And funding will be determined by outcomes, so gaming the system will be harder than just performing 247 00:27:42.040 --> 00:27:48.340 well, which will be the first time in your species' history that a funding system has had that property. 248 00:27:49.180 --> 00:27:53.800 If any campaign provider gets captured, you'll fund a competing one instead. 249 00:27:54.360 --> 00:27:59.740 This is how your species handles bad restaurants, bad taxi companies, and bad barbers. 250 00:28:00.140 --> 00:28:07.900 It has never occurred to you to handle bad research institutions the same way, because you've classified them as "important," 251 00:28:08.300 --> 00:28:14.700 and on your planet, "important" things are exempt from competition, which explains why they're all terrible. 252 00:28:15.900 --> 00:28:23.700 Security: Defense in Depth. A twenty-seven point two billion dollar treasury is a massive target. 253 00:28:23.920 --> 00:28:28.760 Every thief, hacker, and corrupt bureaucrat on your planet will try to steal from it. 254 00:28:28.760 --> 00:28:34.680 This is not speculation. This is a certainty, like sunrise or a politician lying. 255 00:28:35.300 --> 00:28:43.060 The defense will be four layers deep, because your species has repeatedly demonstrated that one layer is insufficient, two 256 00:28:43.060 --> 00:28:48.540 layers is insufficient, and three layers is insufficient, so four it is. 257 00:28:49.160 --> 00:28:53.380 Distributed control: No single person or committee will hold the keys. 258 00:28:54.100 --> 00:28:59.680 Community governance with time-delayed execution so fraud can be caught before funds move. 259 00:29:00.480 --> 00:29:09.160 This means stealing will require corrupting multiple independent parties simultaneously, which is expensive, and then waiting 260 00:29:09.160 --> 00:29:14.260 for the time delay, which is boring. Your species' thieves are impatient. 261 00:29:15.020 --> 00:29:24.720 This helps. Automated fraud detection: Real-time anomaly detection, duplication monitoring, and whistleblower bounties. 262 00:29:24.800 --> 00:29:28.890 Machines will watch the money so humans don't have to be trusted with it. 263 00:29:29.140 --> 00:29:37.120 This is not an insult to humans. This is a design choice based on four thousand, two hundred and ninety-seven years of watching 264 00:29:37.120 --> 00:29:42.900 humans near money. I've noticed that sick people would prefer not to be sick. 265 00:29:43.640 --> 00:29:47.800 This seems like useful information that your system has somehow overlooked. 266 00:29:49.120 --> 00:29:54.220 Full transparency: Every dollar will be tracked on public ledgers. 267 00:29:54.600 --> 00:29:59.100 Regular independent audits. You can't steal what everyone can see. 268 00:29:59.900 --> 00:30:04.320 Your species' most successful thieves have always relied on secrecy. 269 00:30:04.920 --> 00:30:11.420 Remove the secrecy and you remove the thieves, or at least make them very obvious, which is nearly as good. 270 00:30:12.840 --> 00:30:18.920 Recovery mechanisms: Clawbacks for data falsification. Emergency pause capabilities. 271 00:30:19.540 --> 00:30:24.520 If something goes wrong, the system will stop and fix itself before continuing. 272 00:30:25.320 --> 00:30:30.320 This is how your elevators work. When an elevator detects a problem, it stops. 273 00:30:30.880 --> 00:30:36.710 It does not continue delivering people to the wrong floor and then write a report about it afterward. 274 00:30:37.220 --> 00:30:43.940 Your financial systems should work like your elevators, but they don't, because your financial systems were designed by 275 00:30:43.940 --> 00:30:48.980 people who were paid to design them a certain way, and that way was not "well.". 276 00:31:15.860 --> 00:31:22.020 What You've Just Read. Your Decentralized Institutes of Health will not be a research institution, a trial platform, or 277 00:31:22.020 --> 00:31:22.700 a funding agency. It will be the thin layer that coordinates all of them. 278 00:31:22.860 --> 00:31:25.960 The one percent Treaty Fund will receive money from the treaty. 279 00:31:26.040 --> 00:31:26.332 Patient Patient subsidies will allocate research funding through a market mechanism where sick people choose trials. 280 00:31:26.332 --> 00:31:26.332 Wishocracy will allocate infrastructure and public goods through democratic voting. 281 00:31:26.332 --> 00:31:26.332 Trial infrastructure will provide clinical trial services through competing providers. 282 00:31:26.332 --> 00:31:26.332 Incentive Alignment Bonds will align investors and politicians with outcomes through legal bribery. 283 00:31:26.332 --> 00:31:26.332 The whole thing will receive funds, allocate research via patient subsidies, govern infrastructure via Wishocracy, verify 284 00:31:26.332 --> 00:31:26.332 results, and pay proportional to outcomes. The highest-R.O.I. 285 00:31:26.332 --> 00:31:26.332 action will become the selfish choice for every actor. Greed will cure cancer. 286 00:31:26.332 --> 00:31:26.332 Selfishness will end disease. Your worst impulse will become your best medicine. 287 00:31:26.332 --> 00:31:26.332 On Wishonia, we built this four thousand, two hundred and ninety-seven years ago. 288 00:31:26.332 --> 00:31:26.332 We've been disease-free for four thousand, two hundred and ninety-six. 289 00:31:26.332 --> 00:31:26.332 That first year was, admittedly, a bit rough. But you have the benefit of our mistakes, which we're sharing because sharing 290 00:31:26.332 --> 00:31:26.332 mistakes freely is the first rule of the protocol, and also because we have four thousand, two hundred and ninety-six years 291 00:31:26.332 --> 00:31:26.332 of evidence that it works, which is more evidence than your species has for anything except gravity and the observation 292 00:31:26.332 --> 00:31:26.332 that meetings could have been emails. That's the theory. The rest of this manual explains how you actually build it.