What's

interesting is you describe that is what my intuition would tell me, which is that the real lever here is lifestyle. It's the prevention of cancer through things that doctors and research won't help very much with. It's about people's own choices. If you could deal with that, you could make a ton of progress. And then overlaying on that great treatment once you have cancer. But the biggest bang for the buck, really, because it doesn't have to be expensive either, is just getting people to live lives that don't facilitate cancer. I

think that's fair. It's not going to do it all, though. It's really going to take progress on all fronts. It was actually encouraging that our current approach is a really good one in that I don't think we can afford at NIH to pick any one area to solely concentrate on. We have to keep up our focus on fundamental science, on prevention and early disease detection, and on treatment of advanced disease. And then finally, on being able to understand how to best deliver care. We've got to go across all of those fronts.

You aren't just someone who studies cancer. You're also a cancer survivor. Just a few months after taking over as director of the National Cancer Institute, you were diagnosed with early stage breast cancer. And I'm sure that's been incredibly hard, but all in all, it seems like things are going pretty well with that fight.

Yeah, that was a nasty surprise. I am very lucky. My disease was diagnosed early. Very effective treatments were available to me. was brought to mind was when I sat down and looked at the treatment I received and realized, for the first time, frankly, as a cancer researcher who did lots of clinical trials, that there were more than 100,000 women who participated in clinical trials, just the key ones, one for each treatment I received, to produce that treatment. Really, if I tried to add up the numbers, it would be millions of women who agreed to participate in a clinical trial to have somebody flip a coin and decide what treatment they were going to get. The altruism, the bravery of all the women who did that and who was the beneficiary of all that, it was me. When

anybody gets an initial diagnosis of cancer, I'm sure it's shocking and jarring. Do you think for yourself, because you were so knowledgeable about cancer, did that make it easier or harder to get that news? I could really see it going either way. Gee,

I don't know. It's so individual and it affects everyone differently. I will say that by nature, I'm an optimist. I think all surgeons are optimists. I don't think you could be a surgeon if you weren't an optimist. And so when I look at what were the expected outcomes of a cancer diagnosis, I was more of a glass half full than a glass half empty type of view. I think that really helps when you do have something like this happen. In

our society, I think especially in older generations, there has been this sense that illness, cancer should be very private. Just to give you one example, my father, who just retired as a physician, he had cancer for a year or two before my mom even found out. He's still married to her. He had kept it secret from her, and she only found out from a message on the telephone. I have no idea what motivates that kind of secrecy, but I'm curious, in a strange way, because you were leading the National Cancer Institute at the time that your cancer was diagnosed, it turned a potentially very private experience into a more public experience. There was a press release that announced that you had been diagnosed and described your precise cancer, hormone receptor positive, HGR2, negative breast cancer. Was it natural for you to be public about this or something you had to do given your job?

It was very natural, frankly, because I felt I owed it to everyone who had this disease that I wouldn't hide it. You know, I felt like the best way I can support all women out there who also have a diagnosis like this is to be very public about it. And I did get some notes from people and they thanked me for being so public about it and making it very clear to all that a cancer survivor can be even stronger than before.

Maybe you're not allowed to pick favorites, but I'm just wondering if you have a hunch about any breakthrough technologies that could be game-changing in the way that, say, mRNA technology was on vaccines. Is there some approach which maybe isn't yet there, but you can see that maybe it would just be game-changing? I

can give you a couple of examples. One of them is a new approach to combating disease and also doing drug discovery. Tiny little proteins called nanobodies. You've heard of antibodies, right? Antibodies are things that our plasma cells make in order to respond and identify cells that can be targeted by the immune system. Well, it turns out that camels and sharks have a different version of antibodies that are a tiny little fraction of something that acts like an antibody. They're called nanobodies. And they fit into tiny little grooves in cells and proteins and are able to bind cells in different ways and are a really interesting new possible tool in being able to control and target immune behavior and target drug delivery. And part of the reason why I think that's an example of something that could be transformative is the immune system governs so much of what happens in health. Inflammation, a driver of so many of the diseases that disable us, ability to fight tumors, the development of neurodegenerative diseases, and finally, the ability to combat infection. Many of these are related to immune function and immune dysregulation. So this technology has the chance of perhaps being able to be a driver of therapies and interventions directed at immune responses. That's

really exciting. I

think there's another really interesting new result relevant to women's health. Women have much more autoimmune disease. Again, it's an immune effect. You can tell I was an immunologist in my original training because these are all the things that capture my attention most. We've always wondered why do women have so much more autoimmune disease than men? 75% of autoimmune diseases affect women. And there's some really interesting results from a group of researchers at Stanford showing how when the X chromosome, you know, a man has an X and a Y, a woman has two Xs, there are many important proteins coded on that X chromosome. But having two X chromosomes fully expressing all of those proteins is harmful. So what happens is a woman, one of her X chromosomes is silenced. There are certain mechanisms that allow the genes there not to be fully expressed. Well, this group has found that there are some proteins that participate in this silencing of the X chromosome that drive the immune response. And they were able to prove principle of it by taking these proteins, introduce them into male animals, and they produced autoimmune disease in the male animals. Wow,

that's great. Now,

the wonderful thing there is not only do we have a new identification of why women are different than men? Now we have new targets for what we can use to help silence the immune system when it produces autoimmune disease. I've given you two examples. I could give you 200. This is exactly why I say to you, I think it's a fire hose down to a garden hose, because all of these brilliant ideas that are coming out of basic science are really ripe for translation into new therapies. And I think we could do that faster.

So in my mind, I was demonizing pharma in various ways, you know, the way people always do. But then I was just thinking, so let's say that somebody does a clinical trial and they show that some particular therapy works, there's still this problem that if nobody commercializes it, it won't exist. That's another interesting gap. It's not really your problem, but I wonder whether there isn't a social need for an entity that takes the job of taking medical compounds that have immense social value, but they can't put enough money into the pockets of the pharma company to make it worthwhile and nonetheless make those available. I don't know if such an entity exists, but it seems like given what you're saying, we really need something like that. Well,

you've just described the challenge we have with rare diseases. In some ways, we're back to the sickle cell issue. Not that it's terribly rare, but not as common as other things. And you see the tremendous price tag on that. Those price tags sometimes have to do with just the ability to also provide a return to the commercialization partner. Yeah,

I've actually read about that. And so the pharma companies that have the sickle cell treatments, they say somewhat reasonably, look, it costs $2 million, but to live a life with sickle cell is even more costly to the system than $2 million. So we're actually a bargain relative to the existing treatment. Great

example. And

it's not a crazy argument. Research

done at NIH really needs to engage with pharma to be able to succeed in delivery to the people who need it. The Accelerating Medicines Program allows NIH to work directly with pharma partners on issues like this, on development of gene therapy, and on conquering some of these fundamental challenges we have. We also have a small business innovation project that takes a fairly substantial portion of the NIH budget, which provides support for early development to be able to get these promising treatments into clinical development. So this is one of the major focus areas for the intramural program at the NIH. What we do at Homebase, largely it's about these kinds of things, the areas that industry alone is not going to grab and run with.

I sure hope that Monica's optimism about the future of medical research is warranted. Having spent my career as an academic economist, I have to say, I've become somewhat jaded. It's kind of sad, but at some basic level, economists collectively know that what we do doesn't matter very much. It's just rare that an economist comes up with an innovation that has a first-order effect on people's lives. Academic economics always feels a little bit like a game to me. And when I think of medical researchers, I assume they aren't so different than economists, which makes me worry. Maybe, though, the combination of working on problems that really matter and the huge profit opportunities if you succeed brings some discipline to medical research that economics lacks. It's certainly hard to argue with the speed with which COVID vaccines were developed. Let's hope the Cancer Moonshot Initiative has the same outcome. Now is the moment in the show where I invite Morgan, my producer, on to take a listener question. Hi,

Steve. Recently, you were on John Hartley's podcast. The podcast is called Capital and Freedom in the 21st Century. And I thought you were pretty good. Yeah,

John was one of my all-time favorite undergraduate students. And he's now getting a PhD at Stanford in economics. And honestly, I just went on it because I was looking forward to the chance to catch up with John after all these years. I'm shocked that it actually went kind of viral.

Tyler Cowen, who has a podcast but also a blog called Marginal Revolution, about the episode, he said, this is quite simply one of the best podcasts ever.

I never said that about a Pima episode. I think it's just further evidence that I'm better at being interviewed than actually doing interviews.

Well, what was interesting for me is I thought I knew a lot about you, but even I learned something. that is that you're retiring. You're going emeritus in June this year. Yeah,

I didn't think anyone would care. For years on this podcast, I've been saying how I'm not interested in doing academic research. And so by going emeritus, all I'm really doing is assuaging the guilt I have about being part of an economics department and doing nothing that any of my colleagues care about. But all the stuff I actually myself am interested in, the center I run at the University of Chicago or this podcast, none of that's changing. So for me, it was a mere formality. I did find out the hard way, though, that there are a lot of people who expect to be told firsthand that you're retiring rather than finding it out in a podcast.

So apart from all the praise you had for that episode, The Economist magazine did something a little different. A lot of the content from the Hartley podcast was used in a rather snarky article that the magazine published. The title of the article is Why Freakonomics Failed to Transform Economics. I know you have a really thick skin and a lot doesn't bother you, but were you a little miffed by this? I was because of all the media outlets

that you would think might like me and what I do, you'd think it'd be The Economist. And so I heard they were writing a piece about me on my retirement, I thought, wow, this is going to be really exciting. And then when I read it, it was nothing but negative. And I don't get mad about very many things, but this is one thing that actually made me angry.

It's really dismissive of your abortion and crime research. Yeah,

and it's not the first time I went back and looked. three or four times over the last 20 years, The Economist has taken this negative, dismissive stance towards the research on abortion and crime. And it's so frustrating to me because the criticisms are just based so loosely on the evidence, and they completely ignore the fact that not only did we write the original paper 20 years ago, but in an opportunity that almost never arises in academic economics, we made predictions in that first paper about what would happen over the next 20 years. And having waited 20 years, we went back to the data and we analyzed what has happened. And amazingly, in some sense, the results over the last 20 years, every single prediction that we made, there were six or seven of them, turned out to be as truer truer in the last 20 years of data as they were in the initial data we used in that first paper. With evidence that strong, it seems to me just so unscientific that an outlet like The Economist will dismiss our results based on critiques made 20 years ago that we successfully rebutted then and show no interest in trying to update their thinking as our own research has been updated. So that does get me mad.

So we had a few listeners write to us to defend you. And I think they'll be happy to know that you and John Donahue, your co-author on the abortion and crime work, wrote a rebuttal for The Economist that recently was

published. Given how negative the article was, I was surprised that The Economist was so receptive to actually let us write a rebuttal. John and I were given the space to tell our side of the story. And I was glad to do that. I've never actually sat down and in one succinct piece tried to explain why I think people should take the abortion and crime argument seriously. And it was a fun exercise to do. And I'm glad we now have that on record. What

I thought was interesting was your rebuttal with John Donahue only focuses on the complaints against the abortion and crime work. You chose to let all the other points The Economist makes about Freakonomics just fall by the wayside. The

main argument the article makes is that Freakonomics is a failure because it didn't change economics. But that premise is so absurd, I wasn't sure it deserved rebutting because Freakonomics is a book written for a popular audience. It's my academic papers turned into interesting stories working with Stephen Dubner. We never intended for it to change economics. It is impossible, inconceivable that it ever would have changed economics. And maybe you give the writer of that article the benefit of the doubt. And we use just the word for economics. He doesn't mean the book itself, but more the approach that I take to economics. But the thing is, I don't have a unique approach to economics. My academic papers are motivated simply by, can you learn something interesting about the world by looking at the data? And that is what a huge swath of economists do. And I'm a very small bit player in that exercise. And if there's any question about whether that approach generally is having an impact on economics, all you have to do is look at the most recent Nobel Prize winners. That approach to learning about the world has been taking down Nobel Prizes left or right. So that critique in The Economist was completely silly, but it didn't get under my skin the way that the comments about abortion and crime did. We

will include a link to John Hartley's podcast, the original Economist magazine article, and your rebuttal with John Donahue in the show notes. Listeners, if you have a question for us, our email is pima at Freakonomics.com. That's P-I at Freakonomics.com. We read every email that's sent, and we look forward to reading yours.