When You Reach a Fork in the Road, Take It: Science and Product Development as Linked Paths
Keusch, Gerald T., American Journal of Law & Medicine
Increasingly, health is recognized as a major force for economic development; and because economic development is central to political and social stability, health is being looked at as the great hope for the future of the world, as population sizes and disparities among them increase. This perspective has been growing ever since the 1993 World Development Report was released by the World Bank, and it has fueled an intensive scrutiny of health care around the world, focusing on systems and health care delivery on the one hand, and equitable access to the products of research on the other hand. In the middle of all of is this is a concern about how health care (which must include both the training of personnel from the basic low level health care worker to the physician), and research and development (which must include the financing of research in academia and the development of products primarily in the private sector) are organized, and how they do or do not address inequities between and within populations and nations. The purpose of this paper is to provide a perspective from the vantage point of a physician researcher, and to make the case that inclusion of the education and career development pathways of health researchers within the ongoing discussions on the health care and research "system" is essential to achieving future outcomes that, at present, can only be dreamed of. In essence, the argument will be that the education and research system must ensure that the scientific workforce will understand public health needs, that the public health workforce will understand the contributions of science, and that the financial and organizational mechanisms that create the private good of products for better health care can address the global public good requirements for global development.
II. PARADIGMS OF SCIENCE
The goals of science are to both create new knowledge and better understanding of old knowledge through a method that is objective and selfvalidating through constant re-exploration of principles seen to be "established" in order to sustain or refute that judgment. The scientific method is based on gathering observable, empirical, and measurable evidence subject to specific principles of reasoning. In other words, this method is the collection of data through observation and experimentation, and the formulation and testing of hypotheses. As I grew up as a physician-scientist, the system in which we operated within academia was one that rewarded scientific discovery and accomplishment for itself. Our career paths were crudely defined as "publish or perish," the never ending cycle in which research grants support research, papers are published, follow-on research grants are prepared, and academic advancement is based on how successful one is in continually recycling through the grant to research, to paper, to grant circle. Whoever coined that phrase is unknown to us, but the realities of academic success were clear, and we knew what we had to do. Science unpublished was not valued; the value of publication was academic success in terms of funding and position.
The late, great scientist, teacher and Nobel laureate Salvadore Luria, whose course in microbiology at MIT I attended and who some 20 years later I lived next door to in Lexington, Massachusetts, wrote in 1976 that "for the enthusiastic scientist, the scientific enterprise is a monument to humanity's power and freedom - a modern equivalent of the great cathedrals that the burghers of the middle ages raised as monuments to their newly found sense of economic power and freedom."1 He went on to say that "[i]t is a fact of life that science has become so expensive that its support can be justified only on the basis of the benefits that derive from it, which is to say that science has to be justified by the practical technologies that it generates." His concern was that science will be diverted from its more pure purpose of knowledgegeneration through objective methods and hypothesis-testing, to an involvement in "many of the questionable activities of society - a participation that in the long run is bound to undermine the rational heritage of science. …