If you frequent libraries and bookstores here in Canada, you’ll find that Malcolm Gladwell is almost a ubiquitous presence. You cant miss a copy of ‘Blink’, ‘Outliers’, ‘The Tipping Point’ or ‘What the Dog Saw’. Full disclosure though; I’m not his biggest fan. I think he is guilty of accentuating things beyond what they are, and celebrating patterns and statistics which aren’t necessarily as compelling as he makes them out to be. Outliers is a classic example of this kind of thing (maybe his other books aren’t but I don’t know). So recently a very nerdy friend of mine directed my attention to an article he wrote for the New Yorker (last year) about the Pharmaceutical Industry and the process of developing drugs for Cancer Treatment. It is entitled “The Treatment: Why is it so difficult to develop drugs for cancer”. You can find it here. It was definitely a compelling read.
However, if I’m being honest, it only served to reinforce my opinion of him. I hope I’m not coming across as someone who criticises just for the sake of it, I really do have problems with how he lays out his thinking (and of course I’m happy to be convinced otherwise) For what it’s worth, he does do a good job of describing the accounts of people involved in the Pharmaceutical Process. But that is slightly soured by the fact that in doing so, he does caricature and butcher the process of Science and evidence based medicine. Accurate appraisal of the process gives way to ‘interesting-ness’ (and that too of very cliché kind) which I’m not naturally inclined towards.
So here are some of the things I’m not a fan of;
Single study fishing
Just like you can’t extrapolate lab-data to make grand conclusions, the same thing is true of one single study. That’s what he does when he talks about the ‘discoveries’ of treatments. It is implicit in his description of the process that these treatments were grounded out and shown to work from 1 breakthrough study. Which is not at all how it works. Before drugs get approval they get tested and re- tested, and all studies and their methods (and methodological flaws) are reviewed and controlled for – often when regulatory bodies get a hold of this. This is a key – and I would say driving – part of the process. This is what a systematic meta-analysis is, you look at wide variety of studies and trials and you evaluate them and review them as a composite. And if the results are significantly positive after all of that, then we’re talking.
Again the narrative he uses as this ‘mental struggle’ from a group of earnest people (which of course it is and they are) to fight the elements and produce a positive result for their drug, is slightly problematic. Firstly the purpose of evidence-based medicine is to iron out what doesn’t work as much as what does. So negative results are valuable because they can allow us to eliminate what isn’t effective or perhaps indicate problems with the current thinking. The article seems to dismiss those as a complete waste. (Which they probably are from a commercial point of view) They certainly aren’t from a scientific point of view. And Pharmaceutical companies are keen to push this kind of narrative and Malcolm Gladwell – I’m afraid – has done the standard thing here. It certaily brings a fascinating insight into the finding that Industry Sponsored Drug Trials are more likely to report positive results.
Science Innovation vs Business Innovation:
I think a lot of people conflate innovation of business with innovation of science which are two different things. Science moves incrementally with new themes emerging from a framework of older ones and the key thing is the critical evaluation of the evidence behind the claims and ideas expressed. The ‘disproving of hypothesis’ is a central pillar of it all. And in the article he says that the dream of a scientist is to present a paper and then receive a standing ovation from other academics for discovering breakthrough cures. I think it is really lazy to think that science academia works this way. In reality, academics are really ready to tear strips of the papers that are present and they’ll find flaws. Business world works differently. You won’t get someone like (the late) Steve Jobs prancing about on a stage in an academic conference without people scrutinising every single thing he has to say. I’m not making a value judgment as a less moral modus operandi. I’m merely saying that critical thinking and evaluation is much more important in a science-academic setting than it is in a business setting. And at times, I do feel that innovators in business want the glory of science without necessarily subjecting themselves to the same nitty gritty. If they did It would require them to offer caveats and hedges to every claim they make- something which the business world (Of which pharmaceuticals are a subset of) aren’t prepared to do
Compelling human interest angle
Often when you are dealing with Cancer or other debilitating diseases, it is very easy to be sidetracked by people’s stories. It is heart-breaking and you feel helpless, you want to do everything you can to defeat this thing which is causing so much pain and suffering to you’re friends and loved ones. I can certainly relate e.g. personally, I’v had relatives battle and eventually lose to it). Sometimes biases creep in if people bring in sentimentality into the science. Of course support-mechanisms for people are vital when they are battling these diseases. But ultimately, while evaluating the science of cancer treatment, you need more than just good intentions – you need solid, replicated, peer reviewed, statistically significant data sets.