A few weeks ago, I came across a piece in the Boston Globe entitled Sorry, Silicon Valley, but ‘disruption’ isn’t a cure-all. It's a very short op-ed, so I recommend reading it. The piece was written by Caroline Buckee, Assistant Professor at the Harvard T.H. Chan School of Public Health. I know Caroline personally, and given that she has written some of the key papers in digital epidemiology, I was surprised to read her rant. Because Caroline is super smart and her work extremely innovative, I started to ask myself if I am missing something, so I decided to write to her. My idea was that rather than arguing over Twitter, we could have a discussion by email, which we can then publish on the internet. To my great delight, she agreed, and I am now posting the current state of the exchange here.
From: Marcel Salathé
To: Caroline Buckee
Date: 16. March 2017
I hope this email finds you well. Via Marc I recently found you on Twitter, and I’m looking forward to now seeing more frequently what you’re up to.
Through Twitter, I also came across an article you wrote in the Boston Globe (the "rant about pandemic preparedness", as you called it on Twitter). While I thought it hilarious as a rant, I also thought there were a lot of elements in there that I strongly disagree with. At times, you come across as saying “how dare these whippersnappers with their computers challenge my authority”, and I think if I had been a just-out-of-college graduate reading this, excited about how I could bring digital tools to the field of global health, I would have found your piece deeply demotivating.
So I wanted to clarify with you some issues you raised there, and share those with the broader community. Twitter doesn’t work well for this, in my experience; but would you be willing to do this over email? I would then put the entire discussion on my blog, and you can of course do whatever you want to do with it. I promise that I won’t do any editing at all, and I will also not add anything beyond what we write in the emails.
Would you be willing to do this? I am sure you are super busy as well, but I think it could be something that many people may find worthwhile reading. I know I would.
All the best, and I hope you won’t have to deal with snow any longer in Boston!
From: Caroline Buckee
To: Marcel Salathé
Date: 16. March 2017
Sure, I would be happy to do that, I think this is a really important issue - I'll put down some thoughts. As you know, I like having technical CS and applied math grads in my group, and in no way do I think that the establishment should not be challenged. We may disagree as to who the establishment actually is, however.
My concern is with the attitudes and funding streams that are increasingly prevalent among people I encounter from the start up world and Silicon Valley more generally (and these look to become even more important now that NIH funding it going away) - the attitude that we no longer need to do real field work and basic biology, that we can understand complex situations through remote sensing and crowd sourcing alone, that short term and quick fix tech solutions can solve problems of basic biology and complex political issues, that the problem must be to do with the fact that not enough physicists have thought about it. There is a pervasive arrogance in these attitudes, which are ultimately based on the assumption that technical skill can make up for ignorance.
As for the idea that my small article would give any new grad pause for thought, I hope it does. I do not count myself as an expert at this stage of my career - these issues require years of study and research. I believe I know enough to understand that a superficial approach to pandemic preparedness will be unsuccessful, and I am genuinely worried about it. The article was not meant to be discouraging, it was supposed to make that particular echo chamber think for a second about whether they should perhaps pay a little more attention to the realities, rich history, and literature of the fields they are trying to fix. (As a side note, I have yet to meet a Silicon Valley graduate in their early 20's who is even slightly deflated when presented with evidence of their glaring ignorance... but I am a bit cynical...!)
In my experience, my opinion is unpopular (at my university and among funders), and does not represent "the establishment". At every level, there is an increasing emphasis on translational work, a decreasing appetite for basic science. This alarms me because any brief perusal of the history of science will show that many of the most important discoveries happen in pursuit of some other scientific goal whose original aim was to understand the world we live in in a fundamental sense - not to engineer a solution to a particular problem. In my field, I think the problem with this thinking is illustrated well by the generation of incredibly complex simulation models of malaria that are intended to help policy makers but are impossible to reproduce, difficult to interpret, and have hundreds of uncertain parameters, all in spite of the fact that we still don't understand the basic epidemiological features of the disease (e.g. infectious duration and immunity).
I think there is the potential for an amazing synergy between bright, newly trained tech savvy graduates and the field of global health. We need more of them for sure. What we don't need is to channel them into projects that are not grounded in basic research and deeply embedded in field experience.
I would enjoy hearing your thoughts on this - both of us are well-acquainted with these issues and I think the field is quite divided, so a discussion could be useful.
I hate snow. I hate it so much!
From: Marcel Salathé
To: Caroline Buckee
Date: 18. March 2017
Many thanks for your response, and thanks for doing this. I agree with you that it’s an important issue.
I am sorry that you encounter the attitude that we "no longer need to do real field work and basic biology, that we can understand complex situations through remote sensing and crowd sourcing alone”. This would indeed be an arrogant attitude, and I would be as concerned as you are. It does not reflect, however, my experience, which has largely been that basic research and field work are all that is needed, and the new approaches we and others tried to bring to the table were not taken seriously (the “oh you and your silly tech toys” attitude). So you can imagine why your article rubbed me a bit the wrong way.
I find both of these attitudes shortsighted. Let’s talk about pandemic preparedness, which is the focus of your article. Why wouldn’t we want to bring all possible weapons to the fight? It's very clear to me that both basic science and field work as well as digital approaches using mobile phones, social media, crowdsourcing, etc. will be important in addressing the threat of pandemics. Why does it have to be one versus the other? Is it just a reflection of the funding environment, where one dollar that is going to a crowdsourcing project is one dollar that is taken away from basic science? Or is there a more psychological issue, in that basic science is worthy of a dollar, but novel approaches like crowdsourcing are not?
You write that “the next global pandemic will not be prevented by the perfectly designed app. “Innovation labs” and “hackathons” have popped up around the world, trying to make inroads into global health using technology, often funded via a startup model of pilot grants favoring short-term innovation. They almost always fail.” And just a little later, you state that "Meanwhile, the important but time-consuming effort required to evaluate whether interventions actually work is largely ignored.” Here again, it’s easy to interpret this as putting one against the other. Evaluation studies are important and should be funded, but why can’t we at the same time use hackathons to bring people together and pick each other’s brains, even if only for a few days? In fact, hackathons may be the surest way to demonstrate that some problems can’t be solved on a weekend. And while it’s true that most ideas developed there end up going nowhere, some ideas take on a life of their own. And sometimes - very rarely, but sometimes - they lead to something wonderful. But independent of the outcome, people often walk away enlightened from these events, and have often made new connections that will be useful for their futures. So I would strongly disagree with you that they almost always fail.
Your observation that there is "an increasing emphasis on translational work, a decreasing appetite for basic science” is probably correct, but rather than blaming it on 20 year old SiliconValley graduates, I would ask ourselves why that is. Translational work is directly usable in practice, as per its definition. No wonder people like it! Basic research, on the other hand, is a much tougher sell. Most of the time, it will lead nowhere. Sometimes, it will lead to interesting places. And very rarely, it will lead to absolutely astonishing breakthroughs that could not have happened in any other way (such as the CRISPR discovery). By the way, in terms of probabilities of success, isn’t this quite similar to the field of mobile health apps, wich you dismissed as "a wasteland of marginally promising pilot studies, unused smartphone apps, and interesting but impractical gadgets that are neither scalable nor sustainable”? But I digress. Anyways, rather than spending our time explaining this enormous value of basic research to the public, which ultimately funds it, we engage in pity fights over vanity publications and prestige. People holding back data so that they can publish more; people publishing in closed access journals; hiring and tenure committees valuing publications in journals with high impact factors much more than public outreach. I know you agree here, because at one point you express this very well in your piece when you say that "the publish-or-perish model of promotion and tenure favors high-impact articles over real impact on health."
This that is exactly what worries me, and it worries me much, much more than a few arrogant people from Silicon Valley. We are at a point where the academic system is so obsessed with prestige that it created perverted incentives leading to the existential crisis science finds itself in. We are supposed to have an impact on the world, but the only way impact is assessed is by measures that have very little relevance in the real world, such as citation records and prizes. We can barely reproduce each other’s findings. For a long time, science has moved away from the public, and now it seems that the public is moving away from science. This is obviously enormously dangerous, leading to “alternative fact” bubbles, and politicians stating that people have had enough of experts.
On this background, I am very relieved to see scientists and funders excited about crowdsourcing, about citizen science, about creating apps that people can use, even at the risk that many of them will be abandoned. I would just wish that when traditional scientific experts see a young out of college grad trying to solve public health with a shiny new app, that they would go and offer to help them with their expertise - however naive their approach, or rather *especially* when the approach is naive. If they are too arrogant to accept the help, so be it. The people who will change things will always appreciate a well formed critique, or an advice that helps them jump over a hurdle much faster.
What I see, in short, is that very often, scientific experts, who already have a hard time getting resources, feel threatened by new tech approaches, while people trying to bring new tech approaches to the field are getting the cold shoulder from the more established experts. This, to me, is the wrong fight, and we shouldn’t add fuel to the fire by providing false choices. Why does it have to be "TED talks and elevator pitches as a substitute for rigorous, peer-reviewed science”; why can’t it be both?
PS Have you seen this “grant application” by John Snow? It made me laugh and cry at the same time… tinyurl.com/lofaoop
From: Caroline Buckee
To: Marcel Salathé
Date: 18. March 2017
First of all, I completely and totally agree about the perverse incentives, ridiculous spats, and inefficiencies of academic science - it's a broken system in many ways. We spend our lives writing grants, we battle to get our papers into "high impact" journals (all of us do even though we hate doing it), and we are largely rewarded for getting press, bringing in money, and doing new shiny projects rather than seeing through potentially impactful work.
You say that I am probably right about basic science funding going away, but I didn't follow the logic from there. We should educate the public instead of engaging in academic pettiness - yes, I agree. Basic science is a tough sell - not sure I agree about that as much, but this is probably linked to developing a deeper and broader education about science at every level. Most basic science leads nowhere? Strongly disagree! If you mean by "leads nowhere" that it does not result in a product, then fine, but if you mean that it doesn't result in a greater understanding of the world and insights into how to do experiments better, even if they "fail", then I disagree. The point is that basic science is about seeking truth about the world, not in designing a thing. You can learn a lot from engineering projects, but the exercise is fundamentally different in its goals and approach. Maybe this is getting too philosophical to be useful.
In any case, I think it's important to link educating the public about the importance of basic science directly to the arrogance of Silicon Valley; it's not unrelated. Given that NIH funding is likely to become even more scarce, increasing the time and effort spent getting funding for our work, these problems will only get worse. I agree with you that this is a major crisis, but I do think it is important to think about the role played by Silicon Valley (and other wealthy philanthropists for that matter) as the crisis deepens. As they generously step in to fill the gaps - and I think it's wonderful that they consider doing so - it creates the opportunity for them to set the agenda for research. Large donations are given by rich donors whose children have rare genetic conditions to study those conditions in particular. The looming threat of mortality among rich old (mostly white) dudes is going to keep researchers who study dementia funded. I am in two minds about whether this increasing trend of personalized, directed funding from individuals represents worse oversight than we have right now with the NIH etc., but it is surely worth thinking about. And tech founders tend to think that tech-style solutions are the way forward. It is not too ridiculous, I don't think, to imagine a world where much if not most science funding comes from rich old white dudes who decide to bequeath their fortunes to good causes. How they decide to spend their money is up to them, but that worries me; should it be up to them? Who should set the agenda? It would be lovely to fund everything more, but that won't happen - there will always be fashionable and unfashionable approaches, not everyone gets funded, and Silicon Valley's money matters.
Public health funding in low and middle income settings (actually, in every setting, but particularly in resource-limited regions) is also a very constrained zero sum game. Allocating resources for training and management of a new mHealth system does take money away from something else. Crowd sourcing and citizen science could be really useful for some things, but yes, in many cases I think that sexy new tech approaches do take funding away from other aspects of public health. I would be genuinely interested - and perhaps we could write this up collaboratively - to put together some case studies and try to figure out exactly how many and which mHealth solutions have actually worked, scaled up, and been sustained over time. We could also dig into how applied public health grants are allocated by organizations to short-term tech pilot studies like the ones I was critical of versus other things, and try to evaluate what that means for funding in other domains, and which, if any, have led to solutions that are being used widely. This seems like it might be a useful exercise.
We agree that there should be greater integration of so-called experts and new tech grads but I don't see that happening very much. I don't think it's all because the experts are in a huff about being upstaged, although I'm sure that happens sometimes. If we could figure this out I would be very happy. This is getting too long so I will stop, but I think it's worth us thinking about why there is so little integration. I suspect some of it has to do with the timescales of global health and requirements for long-term relationship building and slow, careful work in the field. I think some of it has to do with training students to value get-rich-quick start-up approaches and confident elevator pitches over longer term investments in understanding and grappling with a particular field. I do think that your example (a young tech grad trying to naively build an app, and the expert going to them to try to help) should be reversed. In my opinion, the young tech grad should go and study their problem of choice with experts in the field, and subsequently solicit their advice about how to move forward with their shiny app idea, which may by then have morphed into something much more informed and ultimately useful...
From: Marcel Salathé
To: Caroline Buckee
Date: 19. March 2017
My wording of “leads nowhere” may indeed have been too harsh, I agree with you that if well designed, then basic research will always tell us something about the world. My reference there was indeed that it doesn’t necessary lead to a product or a usable method. This is probably a good time where I should stress that I am a big proponent of basic research - anyone who doubts that is invited to go read my PhD thesis which was on a rather obscure aspect of theoretical evolutionary biology!
I actually think that the success distribution of basic research is practically identical with that of VC investments. Most VC investments are a complete loss, some return the money, very few return a few X, and the very rare one gives you 100X - 1000X. So is it still worth doing VC investments? Yes, as long as that occasional big success comes along. And so it is with basic research, except, as you say, and I agree, that we will never lose all the money, because we always learn something. But even if you dismiss that entirely, it would still be worth doing.
The topic we seem to be converging on is how much money should be given to what. Unless I am completely misinterpreting you, the frustration in your original piece came from the notion that a dollar in new tech approaches is a dollar taken away from other aspects of public health. With respect to private money, I don’t think we have many options. Whoever gives their wealth gets to decide how it is spent, which is only fair. I myself get some funding from private foundations and I am very grateful for it, especially because I am given the necessary freedom I need to reach the goals I want to achieve with this funding. The issue we should debate more vigorously is how much public money should be spent on what type of approach. In that respect, I am equally interested in the funding vs outcome questions you raised.
As to why there isn’t more integration between tech and public health, I don’t have any answers. My suspicion is that it is a cultural problem. The gap between the two worlds is still very large. And people with tech skills are in such high demand that they can choose from many other options that seem more exciting (even if in reality they end up contributing to selling more and better ads). So I think there is an important role for people like us, who have legs in both worlds, and who can at least try to communicate between the two. This is why I am so careful not to present them as “either or” approaches - an important part of the future work will be done by the approaches in combination.
(I think we’ve clarified a lot of points and I understand your view much better now. I’m going to go ahead and put this on the blog, also to see if there are any reactions to it. I am very happy to go on and discuss more - thanks for doing this!)