Why Can’t We Fix Cities and Cure Cancer?

Watching how people approach big, complex problems is revealing. Some start big, looking for a top-down solution. Others start at the bottom, moving small pieces, iterating and creating a feedback loop. I used to be a top-down person, with a belief in clean, elegant solutions that are available with enough analysis. I think formal school creates a bias for this thought process, and it’s not always good. Recognizing this bias, I’ve attempted to “evolve” (an important word) towards the bottom-up, decentralized approach which requires small mistakes.

This is relevant for both cities and the human body, which are complex, always fighting decay and entropy that is natural in systems. The body’s circulatory system carries blood like a transit system moves people, while brains lead our actions like a local government.

Over the past 50ish years, we haven’t gotten our money’s worth in either city-building or healthcare. The car-centric development following the creation of the highway interstate system in the 1950s has attempted to overturn thousands of years of localism. And it has failed. In many places, these single-use suburban developments (suburban office marks, malls, boring residential developments) are failing and will continue to fail, reflectively decades of developers wrongly incentivized to build projects that fly in the face of urban evolution.

The “War on Cancer” began in 1971, with a vow of a cure in 5 years. Nearly 50 years and more than 100 billion dollars later, how far have we come? The industry still relies on blunt “slash/burn/poison” (surgery/radiation/chemo) protocol developed decades ago. Unfortunately, this has gone like the Wars on Drugs and Terror; small wins buried amongst a very expensive failure.

There has been good news in the world of cancer, as some brutal forms such as children’s myeloma can be well controlled for years. The protocols and chemo cocktails have been further refined, making them moderately more effective and less harsh. While survival rates have increased, experts argue that that is largely due to earlier and more diligent diagnoses, which is positive but skews the number. The main victory in the cancer battle seems to be due to the massive decrease in smoking.

Healthcare and cities are enormous pieces of our collective lives, backed by tons of expertise and boatloads of capital that have failed to achieve their promised goals. Why? I think they share similar characteristics of a broader cultural and economic decadence and lack of risk-taking that has slowed down many areas of improvement in the U.S. Specifically: our thinking has gotten too top-down and reductionists, we have been too confident in our own abilities, we have been too focused on short-term results, and we fail to recognize complexity and second-order effects.

Hubris

Cities and cancer have both been around forever, yet we thought we could solve both of them in the last 70 years.

Both urban development and medical research require common sense, a recognition of the big picture AND expertise in the relevant scientific disciplines. Our expertise has lagged the perception of our expertise, apparent technocracy has overtaken common sense and a need for certainty has increased the fragility.

This hubris leads to belief in a single, reductionist answer to complex questions, which manifests itself through large master-planned developments and a search for a single cancer gene.

Poor cost/benefit recognition

Just like the marshmallow experiment, where the ability to delay gratification is a key predictor of future success for children, cities and medicine have been seeking short term victories at the expense of longer-term success. Part of this seems symptomatic with a broader societal short-termism and an inability to solve long-term problems.

When real estate developers kept going further out to build suburbs, cities continue to incentivize them, building more and more infrastructure, all in the name of “growth” and the potential for more near-term revenue. However, the costs have longer duration, and those are coming due now, and will accelerate in coming decades.

The solutions in medical and cancer research seem to be yielding smaller and smaller benefits, with new drugs adding only weeks or maybe months to patients’ lives. And the costs of these solutions keep getting higher and higher, suggesting there is very little juice left to squeeze from the orange. The publicly traded pharmaceutical firms are more incentivized to create a slightly better erection pill, and advertise it like crazy. The cancer solutions are harder, longer dated, more complex and less certain.

Lack of recognition for complexity

Real estate developers and economic development officials moved from making small iterative bets to making large single-use bets that are not adaptive to a changing world. A large big box center housing Circuit City, Toys R Us and Bed Bath N’Beyond underwrite very well, for a specific world, at a specific time. However, that retail property is extremely fragile and unable to adapt in a changing world. Similarly, biotech research has focused on making massive bets requiring billions of dollars and years of trials, focusing on smaller and smaller targets, solving smaller and smaller problems.

To start a chess game, there are only 20 potential moves. However, after only three moves, there are over 9 million potential variations. Cancer is similar. It starts as one mutated cell, but then metastasizes in form in nearly infinite ways. Complex systems require getting as close to the initial conditions as possible.

These are huge areas, and I wish I had the answers. My best suggestion is that we all start small. Make little bets, and make them early. Focus very locally in our communities, working to get local businesses healthy and remaining locally owned. Get involved, and help get tax dollars involved in maintenance and improvement rather than outward growth. On the healthcare side, we should not expect a silver bullet and take more of our care into our own hands. The coronavirus has shown the risk of pre-existing conditions such as obesity and diabetes. A focus more on prevention, overall health and consistent screening seems more robust than waiting for a cure.