Arati Prabhakar on Achieving America’s Aspirations to Improve Health Outcomes

Dean Galea: Welcome to this Public Health Conversation Starter. Today I have the privilege of speaking with Dr. Arati Prabhakar.

She’s an engineer and applied physicist who serves as the Director of the White House Office of Science and Technology Policy, and as Assistant to the President for Science and Technology. In this capacity, she’s the President’s Chief Advisor for Science and Technology, serves as a member of the President’s Cabinet, and is co-chair of the President’s Council of Advisors on Science and Technology.

Prior to her current role, she served as head of DARPA, the Defense Advanced Research Projects Agency. She also led the National Institute of Standards and Technology, making history as the first woman to serve in that role.

I’m really delighted and honored to have Dr. Prabhakar with us today. Welcome.

Director Prabhakar: I’m so happy to be with you, Sandro. Thanks so much for the chance to do this.

Dean Galea: So, let’s start going back. Let’s talk about your background. Tell us about your trajectory and how you came to be doing the work you’re doing.

Director Prabhakar: Yeah, so I got the call from the White House in the summer of 2022 about this role, and I found myself, very quickly, I found myself in the Oval Office, interviewing with the President. And when he asked if I would come do this job at the White House, I said yes so fast it would’ve made your head spin.

And the reason is that I had gotten to spend half of my professional life in public service, running DARPA and NIST, two extremely different federal R&D organizations.

The other half was Silicon Valley, most of that venture capital, a couple of companies.

And what I had seen in American science and technology and innovation—I got to participate in it from lots of different perspectives—and what I saw was we do huge things.

We do astonishing things in this country and we love the lone hero narrative, but that’s actually not how anything works. Because every big thing, the information revolution, curing diseases, the clean energy capabilities that we brought forth, every one of those took public and private. It took people in universities and people in companies and people in civil society and in the policy world.

And my great passion became how do we nurture our innovation capacity so that it allows us to succeed at the great aspirations that we’ve got for now? Because our aspirations are vast, they’re phenomenal, they’re incredibly challenging. How do we meet the climate crisis? How do we change American health outcomes?

These are things we have to do. We don’t quite know how we’re gonna get there. And that, to me, is a clarion call for innovation.

And to get to work on that for a president who believes this country can be defined by the single word possibilities, I just thought that was the best thing I could have possibly been asked to do. And I’ve really enjoyed it for the last two years.

Dean Galea: So, before we talk about the past two years, give us a bit of a primer. So, you led the National Institute for Standards and Technology and DARPA, and now you lead the Office of Science and Technology. Can you just lead us through what the responsibilities of these three organizations are?

Director Prabhakar: Yeah. DARPA’s the Defense Department’s core research and development agency. It was started in the wake of Sputnik, when we realized that, yes, we need to do all the research that the military already knows it needs, but we also need a place that comes to work every morning to create surprise, so that we’re not surprised by Sputnik, but we create the surprises that shape the course of history.

And what came out of that, over many years, was literally the internet started at DARPA. Stealth technology and precision strike, which completely changed military combat, came out of DARPA. Much more had to happen, but it’s a place that sparks revolutionary ideas.

While I was there, I got to start the Biological Technologies Office. And one of the things I’m really proud of from the time that I was there is the work that one of my program managers did.

In 2012, he told me, when I showed up as DARPA director, he said, “We’re gonna have another pandemic.” All of you in epidemiology knew this in 2012, but the rest of the world was not paying attention. But my program manager said, “We’re gonna have another pandemic. We don’t know how to make vaccines in fewer than years or decades or never.” “But,” he said, “there’s this research in mRNA, and it could be the basis for a rapid response vaccine platform. And I just found this company, this brand-new startup in Boston, called Moderna. They wanna work on mRNA for cancer, but we might be able to talk them into working on infectious disease,” which is not a market that anyone thought was gonna be lucrative in 2012.

And it turns out, with a big vision and some funding, you actually can get people to do something very different than what the market was gonna do anyway. And, again, so many miracles had to happen for us to have this extremely safe and effective mRNA vaccine for COVID-19.

But that’s a great example, to me, of sparking something in 2000, you know, a decade before the pandemic, or almost a decade before, at a time when it was considered crazy.

So many people told us we were nuts to be working on mRNA vaccines back then. So that’s an example of DARPA.

NIST is a place that lays the foundation of measurement standards and technology for the entire commercial enterprise. It’s about weights and measures. It traces back to the Constitution.

And today, that includes how do you accurately measure, you know, how do you actually calibrate your complex systems for measuring and assessing molecules and building nucleic acid sequences? So, it’s a very broad mission that they’ve pursued as technology has changed. It has a lot more jobs today.

And then this role at the White House is one, and part of the reason I love it is it’s a place that looks across the whole innovation system, of course, particularly the questions of policy and the federal, the public investment in R&D.

But the point of the exercise is to see that whole picture and to see how all the pieces play together, and to bolster and make sure it’s healthy, but also to aim it at the great challenges that we have today ’cause our innovation capacity largely grew up in the last century. And, you know, the world’s a little different now.

Dean Galea: Hmm. Okay. So big picture. That’s perfect. So, let’s talk about big picture now. So, what’s your take on the state of American health right now? How are we doing compared to peer countries? And from your perspective, what are our biggest challenges?

Director Prabhakar: Yeah, well, this is the world you all live in, so I’m not gonna tell you anything you don’t know. But I think we have really bad news that we have to just look in the face, to say that American health outcomes simply are not acceptable for the wealthiest country in the world.

As you know well, there are, you know, like at least three dozen other countries that have longer life expectancy than we have. So, clearly, we have an outcomes problem. And, you know, the lay of the land is not good today. When you look at rates of obesity, food insecurity, lack of regular exercise, it does not bode well for the future.

And, secondly, we have a very significant equity issue. Again, this is something you all know well, and I think this is part of why public health is foundational to fixing this problem.

I’m just astonished when I look at disparities across ethnic groups. Life expectancy varies by as much as 16 years. And if you look across the counties in this country, a 40-year gap in life expectancy. Think about that, 40 years’ difference in life expectancy. So, we have an outcomes gap, an equity gap.

And, finally, I think we have a huge implementation gap. And I’ll tell you the story

that has really stuck with me. There was a wonderful series by the popular historian Steven Johnson about how humans doubled our lifespan, right, over-

Dean Galea: On his last book, yeah.

Director Prabhakar: Yep. And the story he told that really stuck with me

is we all love to talk about Louis Pasteur, white lab coat. He discovers that pasteurization, you know, can fix this problem of poisoned milk, which is killing school kids in industrialized cities at a phenomenal rate across industrializing America, right in the middle, now we’re in early 1860s.

So, and in the scientific community, we celebrate that, that aha laboratory moment. But it took us a half century before we actually stopped poisoning school kids in industrialized cities with spoiled milk.

And you all, I mean, you will recognize all the reasons, right? Like, the milk didn’t taste the same, so consumers didn’t like it. Why would producers spend more to treat the milk for consumers who don’t want it?

It finally took a philanthropist providing pasteurized milk to an orphanage, which had horrific death rates, to prove how dramatically it could change outcomes. It took a presidential study. I mean, so many things had to happen, but 50 years before we actually stopped poisoning our school kids with this stuff.

So, you know, and I wish I could tell you that we have gotten faster, but when I look at how long we have known about smoking’s impact on lung cancer and other deaths, you know, we simply can’t get where we need to go if it’s always gonna take us half a century.

So, it’s an implementation issue on top of everything else.

Dean Galea: So, let’s talk about the implementation. From your perspective, from where you sit, but also based on your background and all your experience, what’s it going to take to move the needle on health nationally?

Director Prabhakar: Yeah. I painted a really dark picture because I think we have to be blunt about where we are, but I am far from hopeless.

 And part of what has given me a great deal of hope is the work that we’ve gotten to do in my office on the Cancer Moonshot. And I think folks know that this is an initiative that President Biden and First Lady Dr. Jill Biden started when he was vice president.

They reignited it when he was back in the White House as president. And when they reignited it, about 2 1/2 years ago, they set up two really important, aggressive goals.

One was to cut the age-adjusted cancer death rate in half over the next 25 years. That’s about twice the rate of progress. That would translate to millions of lives saved in that period. And, secondly, a qualitative goal, which is to change the experience of people going through the cancer journey, for patients, but also family members and caregivers.

And when I came into this job, part of the reason I was excited was I thought, you know, I love setting a big, bold, aggressive goal that really changes people’s lives. The number one question I had was, were we just gonna write a bunch of great research papers, or were we gonna move the needle on cancer outcomes?

And then I met Danielle Carnival, who runs health outcomes now at OSTP and runs the Cancer Moonshot for the President and the First Lady. And five minutes after you meet Danielle, you know the answer is we’re gonna move the needle on cancer, and here’s why.

It’s because the program has taken a systems approach and has said, “If we’re gonna get there, if we have to meet these goals, we have to do much more to prevent cancers.

We have to do much more with early detection and screening so that we can nip, there are many cancers that we can nip in the bud. And we have to make sure that we have good treatments, but also that those treatments reach everyone, not just the few who can afford them and have access to care.”

And there’s so much that has gotten done in each of those categories, but, to me, the bigger message is that really moving the needle on a hard, complex problem like American health outcomes does require action at all of these levels, rather than, I think, you know, so much of the research we do under the rubric of health really starts at the molecules and, unfortunately, sometimes stays at the molecules.

And it does not really take a systematic view that says, “These are all the things that we need to get where we need to go.”

Dean Galea: So lead us through what the Cancer Moonshot has done and what it has achieved.

Director Prabhakar: Yeah, so I’ll start with prevention. Several actions, but the one that I think is probably the most significant at the end of the day, the EPA has now put in place drinking water standards, safety drinking water standards, first-ever standards across the country.

This is about PFAS, which, the more we learn, the more concerning it is to see what its health effects are. And so over 100 million Americans, as these regulations get implemented, will have a protection from PFAS.

We’re doing the work, we’re making the investments to get rid of lead in drinking water. By the way, we have known since before Christ that lead in drinking water was a bad thing. So that one’s more than 50 years.

The EPA finally banned the last form of asbestos, which, you know, again, we’ve known for decades, but there was still one form of asbestos that there were lawsuits. It took forever. There had to be new legislation. We finally got that banned. So those are important issues about environmental toxins.

We’ve also significantly enhanced access to smoking cessation programs, because, again, we know that that’s still gonna be one of the most important anchor areas. That’s prevention.

If you look at screenings, I’m sure you all saw the really concerning drop in screenings during the pandemic. I think Americans missed about 10 million screenings in 2020. And we’ve done a lot of work to make sure that that fully rebounded. But, of course, the people who get screenings are the people who have insurance, access to primary care.

And so, we’ve also done a lot of work to reach communities that have not been well-served before, from tribal communities, rural communities, lower-income urban communities. And expanding that reach is really, really critical.

The President has put an enormous focus on making sure that we serve our veterans. And the PACT Act really focuses on, first and foremost, acknowledging that so many of our active-duty military service members were exposed to really quite challenging toxins.

And simply being able to screen and know who had those exposure so that they can get the care that they need, should they develop illnesses, including cancer. That’s been a major change. All of that is part of screening and early detection.

And then, for delivering care, when people do have a cancer that needs to be treated, I think some of the most significant work that has been done is what you know about, that’s generally about better insurance and lower costs. So, the largest number of Americans today have insurance that we have ever had, because of the Affordable Care Act and a lot of work that President Biden did to extend its reach.

He’s lowered healthcare costs and medical costs, medicine costs, including the price cap, the cost cap for seniors at $2,000. What that translates to is people who could not afford cancer drugs now being able to get cancer drugs and actually complete their therapies.

And I’ll just end this long list with something that I think is a really important example of meeting the human needs of people going through the cancer journey. The First Lady, in particular, did a lot of work to make sure that we changed access to patient navigation services for people who are experiencing cancer.

And, you know, what that means today is over 150 million Americans now have an insurance coverage that will reimburse for patient navigation services. And we are boosting that profession, and making sure more and more care providers can provide that service.

I keep coming back to a meeting I had with a cancer survivor who told me about how, what he said was that the doctor told him he had cancer and he didn’t, like he didn’t even know where to start thinking about it. And he said, “My world stopped spinning when I met my patient navigator because that’s how I started being able to figure out, step by step, what to do.” And he said, “Even how to tell my family.” And I just found that really, really moving. But, you know, that is so integral to people being able to get through this process. And I think it’s a great example of, you know, taking this holistic, very human-centered approach to dealing with these issues.

Dean Galea:There was a bit of a masterclass about how health happens, prevention, screening, better access to care, better care, better therapeutics and-

Director Prabhakar: That’s what you all do, right?

Dean Galea: That is essentially the full spectrum. So, thank you for that. Let me ask you a question about technology for a second, because maybe leaning a little bit on your DARPA experience, but, in general, talk a little bit about the role of technology in creating a healthier country.

And perhaps, if I may, if I might inflect my question a little bit, you know, sometimes I worry that there are two extremes in how we intersect with technology. One is the app is the answer to everything, using that simplistically. And the other extreme is, no, no, technology is a distraction from what matters.

And so, I’m wondering how you’ve navigated that space.

Director Prabhakar: I love this question. So, I’m gonna add a third piece to the two that you said that I really agree to, which is that technology is the cause of health problems, right?

And as it happens, I think all three of those are true. And navigating that and figuring out how to get what the technology might offer, but turning it into real change in outcomes, while managing the fact that everything, from how it’s so isolating for kids, mental health issues, that seem closely linked to what the people are experiencing online. And it’s not just, I mean, we use the terms misinformation and disinformation. There is a distortion of reality that is going on in the information sphere that is extremely damaging, including to people’s physical and mental health.

So, yeah, so I think there is a lot to navigate. I’m actually pretty hopeful that the possibility of using technology for, you know, just for something that’s really easy to say and almost impossible to achieve, which is healthy habits, right?

Like, I think that promise is still out there. It surely has not been realized by the kinds of apps and the way that they are being used today. So, I think the hype, you know, there’s a hype cycle, but I’d like to get to the other side of the hype cycle, where we actually find ways to use it.

And, you know, here are a couple of things that I think are promising.

The bright side of what we’ve seen in social media interactions is a way that people form communities and shape their beliefs and behaviors. So, if you are part of a community that is helping you stay on track with your healthy habits and reinforcing your good behavior and you’re egging each other on, you know, that’s a direction where you can see how this might actually be constructive.

 I think we’re living in a time where the negative spiral that happens in those environments is so overwhelming that it’s hard to imagine how we would navigate to that. But I think that might be something that is still very worth exploring and pushing on.

Dean Galea: I like the point about things that are easy to say, almost impossible to achieve, which I agree with completely.

Let me, to talk a little bit about your work in your current position, your work with President Biden and the science policy at the high level. Talk us through how the President thinks about science policy, and talk us a little bit through, about how science has infused the work of the President and this Administration over the past four years.

Director Prabhakar: Yeah. Yeah, and it really starts, for this President, I think it really starts with his vision of what this country is. And I remember the first time, he says, and I can’t tell you how many times I have heard him say, he tells a story about meeting with Xi Jinping and, you know, being asked, “How would you define America?” And he says, “I told President Xi that America is a country that can be defined in a single word, and that word is possibilities.”

And I have now heard that story an uncountable number of times, but I remember how it made the hair stand up on the back of my head the first time, because that is what I see when I see this country.

And for me, it is intimately linked to this idea that we, the people, get to invent a better future. And science and technology and innovation, that is its purpose, is to create a better tomorrow than the yesterday that we’ve just lived through.

And when I talk to the President, it’s really apparent to me that he sees science and technology very much in the same mode, that it is something that we are creating for a better future for all of us.

And, you know, like if you live in this world and you think that way, it’s obvious. Not everyone really thinks about it that way. So, I find that really exciting.

It manifests in lots of ways. And the first is simply, you know, going back to the 2020 campaign, when we were in the height of the pandemic, he was extremely clear that he was gonna build an administration that was built on scientific fact. And just a very practical approach that says scientific integrity and trust in scientific results is foundational to everything we need to do. And that facts are handy things, that they help you make better decisions about the future.

And I think sometimes the scientific community is preachy and sort of says, “This is a religion and you must believe us.” But, to me, the whole point of science is it is not a faith-based religion. It’s about facts, the best facts we have at any moment in time.

We’re gonna keep getting smarter, but why wouldn’t we use the best facts we have at any moment in time to help us make the choices about how we function in this world? We know that’s gonna help things turn out better.

So I think that very practical focus on just trusting scientific facts and reinforcing scientific integrity, that’s the starting point. And then he’s been very clear that he sees the public investment in R&D not just as something that we do because, you know, we like scientists and we should make sure that they’re well tended, but because they are making a pact with America to deliver a better future, to open the doors so that we can tackle our hard problems and create a future with better health. And one in which we use technology to reinforce our values, rather than erode them, and a future with economic prosperity across all regions of the country.

So, it’s very purpose-driven and, you know, which is, I really resonate with that because, you know, I started off not as a scientist, but as an engineer. And the engineering approach to thinking about technical things is, well, our function in society is to build capabilities that serve some purpose. And so, this whole approach really resonates for me as well.

Dean Galea: So, let me pick up on one last thing you said. I wanna ask you about, in this role, and also you spent a lifetime thinking about these things, how you see the balance that societies have to strike between what we know scientifically and other values that society holds dear. You mentioned about the economy. And, you know, in my speaking and writing, for example-

Director Prabhakar: So important.

Dean Galea: I use the banal example, but I think a helpful example, for example, speed limits. You know, we know that if we lower speed limits to 25 miles per hour everywhere, the science shows us pretty clearly that it actually saves lives, but we don’t do that.

 And so I’m wondering about your reflections on how one balances the science with other values that society thinks are important. And, obviously, some of this played out in the context of COVID, with economic productivity.

Director Prabhakar Oh, so many ways.

Dean Galea: So I’m curious about your thoughts on that.

Director Prabhakar: Now, I mean, I think you have actually done a great job talking about exactly this issue. The facts are the facts, but what we choose to do about them reflects our values. And, you know, I think speed limits are actually a great example.

Maybe just to pursue that one, 40,000 people lose their lives in traffic accidents in the United States. On a per-capita basis, that is appalling compared to most other countries that have highly developed economies and lots of transportation and lots of cars zipping around.

And Secretary Buttigieg, our secretary of transportation, he’s been a passionate fighter for dealing with this issue. He reminds people that it’s the equivalent of, you know, an airline crashing every day, basically, right? But, somehow, we don’t even think about it as a major issue.

So those are places where we’ve made bad choices and we are living with the consequences. But shining a light on it is part of asking, again, and being deliberate about something that we have slid into. To say, “Is this really okay? Is this really what we want to do?”

And I think that question, you know, we’re at a moment right now of great uncertainty for the course of the country. Clearly, change is afoot.

I think it’s very hard to predict what it’s gonna be, but I think through all the changes that are coming, it’s gonna be very important to be grounded in facts, and then be very clear about what our values are so that we can steer and navigate through what I think is gonna be very choppy waters.

Dean Galea: Yeah, so let’s talk about that. We’re sort of 2/3 of the way through our conversation. So, let’s talk about, really, the hard questions.

So, we’re recording this in end of November of ’24, and we are gonna be entering new administration come January of ’25. Let’s talk a little bit about your thoughts about what this is going to mean for health, and what all of us who are in this conversation, who care about creating a healthy country, should be doing to intersect with this moment.

Director Prabhakar: First of all, I think it’s, I can’t predict. You may be able to predict, but I can’t predict.

Dean Galea: Oh, no, I certainly cannot.

Director Prabhakar: I think it’s a time of uncertainty, and part of the reason for the uncertainty is that the incoming administration, the members of the incoming administration, have said a very wide range of things, ranging from things that could actually be aligned with promoting better health outcomes, and things that would be tragically devastating to maintaining even the level of health that we have today.

So, I think it remains to be seen, but, again, whenever we are in choppy waters, I think it’s even more important to be clearer about what we’re navigating to and to be anchored in our values.

And so, let’s, you know, let’s talk about a few simple things.

One of the great American ideas is the notion that individuals can set their own course. And it’s a liberating and an empowering idea. But the reality is that how this country has progressed over a couple of centuries is by also making sure that we take care of each other. And when you look at health, there are things that we each need to do for ourselves, but we also are social creatures.

We live in communities that have housing and transportation that might look one way or another, access to good nutrition that might look one way or another. Infectious disease is something, you know, if I have diabetes, then you and I hanging out together, you know, unless my bad eating and exercise habits influence you, which is also social contagion, that’s a different story, but if I have an infectious disease and I’m sitting next to you, my problem is your problem.

And recognizing and being clear that so much of what shapes health is not just about the individual, but is about the community, the society that they are living in day to day. That’s just a simple fact, but it should tell us something about how we navigate to maintaining and then expanding health in this country.

So, I mean, this is, again, I really admire the work of the public health community because I think you are integral to that understanding. And I think it has been a challenging time for the public health community, coming through this pandemic. But, you know, I think about the public health leaders in the places that I lived in the pandemic, and I think they are heroes.

So, I think it’s a time to stay engaged, to take deliberate action. You know, I’m thinking about all the students here. The fact that you are choosing to study public health, the fact that you’re gonna go choose careers and go to work every day to make things better for people across the community, those are the most significant choices that individuals can make today.

And I think it’s a time to stay engaged with the broader political dialogue and make sure that your voice is heard so that the facts that you bring and the values that you bring are part of how this story turns out.

 And the most important thing is what my boss, the President, always says, which is keep the faith because we can’t let go of what really matters to the people in our community and to the thriving of our country.

Dean Galea: Thank you. Let me talk about sectors for a second. Let’s talk a little bit about (indistinct). You’ve worked in all these sectors, which is extraordinary. Let’s talk about the federal-

Director Prabhakar: I can’t keep a job.

Dean Galea: Let’s talk about the federal government. How do you see the role of the federal government in terms of advancing progress in science and health? And then I’m gonna ask you about the private sector, but let’s start with federal government.

Director Prabhakar: Yeah, well, first of all, my starting point is that nothing big ever gets done by any one sector or entity or individual. But the public role, let’s talk broadly about research and development. The public role has laid a vitally important foundation.

And let me break it down into a couple of different pieces. So, if you take federally funded R&D, a number of the investments that we make with public dollars are for public missions.

So, I worked in the national security sphere. That’s something we count on our government for. It absolutely requires deep and intensive research and developments,

and that has to be a public investment.

Health is a shared public and private responsibility, the way we have structured things in our country. But for many, many decades, we’ve been clear that the public investment in research is foundational for everything in our healthcare system.

I’d like to make sure we think of that not just in terms of healthcare, but health more broadly. But that’s been a long-standing commitment.

Energy is another area where there’s shared public and private, and we make significant public R&D investments. Space exploration. So, there are a whole host, agriculture, a whole host of public missions that require R&D, and that’s part of what we do.

The largest, overwhelmingly, the largest amount of funding in R&D in our economy today comes from companies. And, but I think we need to be clear that the public R&D investments that we make, NIH, but also the National Science Foundation, many other parts of research from the federal government, that lays a vital foundation even for the private sector investment, because those dollars are educating the students that they hire to develop new products and services.

It’s laying a foundation of basic research, that individual long history of economic assessment that shows that private companies won’t fund the basic research foundation that they all need to build their own products and services on top of. And so, you know, I think in the ecosystem, we can’t live without the piece that the public R&D does. And one of the things this President has emphasized is making sure that it is robust enough, that it’s funded highly enough, to keep up with the scale of our ambitions.

He was able to get a 24% increase in federally funded R&D in his first two years, before the budget caps hit. And now, you know, everything has stalled because of that. Everything in discretionary spending, including R&D, has stalled because of that. But that’s the public component.

And, you know, it’s hard to think of any major health advance that we’ve had in this country that would have happened without that public foundation. So, it’s just essential.

Dean Galea: Now let’s go to the private sector. You spent 15 years in Silicon Valley,and you were in venture capital and executive in companies. So obviously been really interesting to see howthe evolution of the influence of Silicon Valley in the past couple decades.

Director Prabhakar: Yeah, it’s interesting.

Dean Galea: You’ve lived through that.And guide us through, I suppose the general question is the role of the private sector.But a more specific question is how does one harness the energy, enthusiasm, entrepreneurial spiritfor good, recognizing that there is potential for good and bad in all this energy and enthusiasm?

Director Prabhakar: Yeah, that’s exactly right. Look, one of the phenomenal characteristics of this country is financial markets that are the best the world has ever seen at allocating capital as soon as profits and growth are visible. There’s nowhere better. And the amount of capital to go pursue business opportunities, once profits and growth are visible, the amount of capital that’s available is just mind-boggling. And so, you know, that’s a great strength.

Left unfettered, we know what that looks like because for a long time, we had an oversimplified assumption that the market was gonna solve everything for everyone. Turns out, it solves everything for a few people.

It does a lotta good, but it certainly does not solve problems for everyone. And it has created, it has hollowed out parts of our country and left us with all kinds of issues to deal with. So that is the adjustment that President Biden really set out to make, is a new era of a different approach with the government and the marketplace. Finding a new way to partner to do the country’s work in a more effective way.

And that is, to go outside of health for a minute, that is behind the fact that under his leadership, we’ve now made the first really significant investment in the clean energy transition that anyone, anywhere in the world, has made. We are finally deploying clean energy at a scale that the climate’s gonna notice, right? Like, if you build a billion-dollar company, good for you. The climate will not notice ’cause that’s just not big enough. But now we’re talking about a trillion dollars’ scale of capital, public and private.

So, the climate’s actually gonna start noticing. And that is not because we poured a trillion dollars of taxpayer money into it and drove the industry. It’s because we catalyzed the private sector and got a lot of private capital to move, with a little bit of public capital.

So that is an example of the kind of redefinition of the interaction between government and industry that the President has embarked on, I think with tremendous success. So, the impact from that is gonna play out for many, many decades.

Thinking specifically about Silicon Valley, I’ll tell you a very sobering moment I had.

I joined a venture capital firm in 2001, and my area was semiconductors, but my firm invested quite broadly across all kinds of technologies and businesses. And I had healthcare partners, and I thought, great, you know, venture capital could actually do something about improving American health.

And then it sorta broke my heart, but I very quickly realized that the only things that my partners found to be investible were big, expensive, end-of-life cures for things that already had a reimbursement code. And so, you know, there were markets, and you could count how many people and you could count how much life extension, and I’m all for it, but it had zero to do with changing health outcomes for the country and dealing with all of the issues that we’ve been talking about here today.

So that has gotten, I think, somewhat better because of the changes under the Affordable Care Act and some of the measures that, you know, tie reimbursement to outcomes.

So, it’s not that we’re stalled, it’s not that nothing is making progress, but when you ask me what’s gonna really change American health outcomes, the answer is not gonna come solely, and perhaps even in any significant way, in my view, out of simply, you know, startups in that model.

It’s not really what it’s designed to do, in my view.

Dean Galea: Let me ask you one particular question about technology, AI, ’cause it’s in the conversation.

Director Prabhakar: Oh, my gosh, that’s a huge-

Dean Galea: Because everybody is talking about it right now. I thought I would just barrel down, just for a second, to tell us a little bit, two questions, I suppose. Number one is your thoughts, actually, about the evolution of AI in the next five, 10 years as it intersects with health in particular.

Director Prabhakar: Great.

Dean Galea: And number two is the regulatory role as AI rolls out and takes on a greater prominence in our space.

Director Prabhakar: Yeah, this is so interesting. I started a month before ChatGPT came out into the world. So, my agenda got completely hijacked by AI, but in a really constructive way.

And the reason I say that is that it is this new force that is reshaping virtually every field, every field of research, but also every dimension of our lives. And so it became a lens through which to explore what was gonna happen in health and in climate and all the other things that we work on.

AI was already in our lives in so many ways before chatbots and image generators, but it used to be hidden. You know, it used to be you got a ticket price from your airline, but you didn’t think about the fact that an AI model had profiled you and generated that price. And you really didn’t think about the fact that when you went to the ER, that there was probably an AI model behind your diagnosis or treatment.

But chatbots and image generators are in our faces. And so people, all of a sudden, it felt like they were seeing AI very directly and they could do astonishing things. And what has happened over the last couple years is President Biden and Vice President Harris really used that moment to say, “We’ve gotta get the country on the right track.” And the right track means, with the powerful technology that has both promise and peril, the right track means both managing its risks in order to seize its great benefits that it can offer.

And so a lot of work has gotten done to manage risks. Almost all of it is of the flavor of, discrimination and fraud, for example, are already illegal. Let’s make sure that we’re enforcing when those illegal things are being done with AI. And that’s easy to say, and hard to do, like many things we’ve talked about today, because AI gets used so pervasively. And when it is used to choose to such a broad scale that, for example, when it’s used to determine, you know, whether you get a loan or a mortgage, you might not even be aware that it is being used in your evaluation.

And the biases that it can embed from faulty decisions that were made in the past, now it sort of distills all that bias and now allows you to do that at scale. So they can be quite problematic in areas like housing, lending, healthcare. Obviously, a driver of fraud. But those are all areas where I think today, we are starting to make progress.

And I’ll give you a specific example in the health arena, which is that the Department of Health and Human Services now has a rule that if AI models or systems are being used in medical treatment and medical care, that the healthcare provider has to determine that it’s not embedding the kinds of biases that, you know, not just distilling the bad decisions of the past.

So, there’s a lot more work to be done, but I’m really proud of what we’ve been able to do to set the course in the right direction for managing risks. And, again, the reason to do all of that is so that we can use this powerful technology to solve some of our, you know, breathtakingly hard problems.

A question I’m really interested in is ideas about how AI helps us in public health. And I’d love to hear ideas that all of you have. The obvious things that come to mind is, you know, a lot of things that are happening already in the provision of healthcare is trying to alleviate the burden on healthcare providers.

So, their lives have been, you know, tortured, right, by turning into people who have to type and deal with information systems, rather than patients. Those are things that can get better. I have optimism about that.

But I wanna know if we can detect infectious disease outbreaks much more quickly because AI is terrific at seeing subtle patterns emerge out of noise. And then an area where we’ve done a lot of work, and President Biden’s new agency, ARPA-H, the ARPA for Health, just launched a big program, is, you know, people have had this vision for a long time that AI trained on biological data and clinical data could be used to design drugs much more rapidly.

And we did a lot of work to dig into what does that really mean and what would it take? And ARPA-H recently launched a program called CATALYST that is the first bite of that, which is an attempt to build, to develop an AI model that’s trained on clinical data.

And part of the magic here is getting companies to part with their proprietary data for training purposes. But the notion is an AI model for toxicity in pharmacokinetics, a toxin (indistinct) model that the FDA would certify. And that if your new compound passed through that model and got a check mark, that that would accelerate your progress, accelerate you directly into a phase I clinical trial.

So, it’s not the complete revolution of design and approval of new drugs, but think what a big deal it would be if you could show that even that first stage was possible. So, it gives you a glimpse of how powerful it can be if we do it right.

Dean Galea: My last two questions. Let’s talk about the academia, universities. From your perspective, currently, the Cabinet Secretary, a life in innovation, science and technology, what’s the role of academia? How can academia be most effective?

Again, to influence my question a little bit, I can’t help but feel sometimes academia gets, is misunderstood and gets a bad name for sort of saying, “Well, you’re just producing papers.” So I’m just curious how you see academia as part of this ecosystem of creating a better world.

Director Prabhakar: Yeah, so many ways. And I wanna be really clear that one thing we absolutely need from academia is to continue to produce those amazingly important and rigorously done research papers, but it’s also a time when that’s just not enough.

And so, so much is already happening that we have to make sure it continues to be strong. Strong basic research, the education of students, those are things that are jewels in the crown here in America, and we can’t let those wither and decline.

And it is a time when universities are being called to serve a greater function in society. And, you know, a school of public health knows this because it’s integral to your mission, I think it’s how schools of public health think about the world, but these are places where research is tied to working in the community and educating students who are gonna go out and do, take what they’ve learned and apply it in ways that directly change people’s lives.

But I think there’s a lot in what has worked well in us, for example, in schools of public health, that we need for the broader research system so those beautiful research papers don’t just languish on the shelf, but they actually turn into economic activity and opportunity across regions of the country.

I mentioned ARPA-H as something I think is amazing that the President added to the mix of innovation and health. Another thing that I think will have long-lasting implications is the National Science Foundation, under this President, started the first new directorate in 30 years.

And it’s a technology, innovation, and partnerships directorate specifically to complement the core NSF, which funds the foundation of basic research across virtually every field. This new directorate is doing things like helping universities that haven’t yet established the capability to do tech transfer, to license the results of their research or to help startups build that capacity.

It’s also running a whole set of regional innovation engines where communities are invited to come together to have local business, community colleges, research universities, labor organizations, come together and determine what they think in their region could be the foundation for fresh, exciting economic opportunity.

And then NSF comes in and helps fund and partner with the directions that they think are gonna create real growth and opportunity for people across their communities so that we have the kind of flourishing economic development that comes out of research, not just, you know, in Cambridge and Boston and in Palo Alto, but across the country to really strengthen our communities.

Dean Galea: Okay, so let’s end the way we started. Let’s end on hope.

I think we should always end on hope.

Director Prabhakar: Always.

Dean Galea: Talk to us about hope and what gives you hope in this moment.

Director Prabhakar: I was in the Rose Garden a couple of days after the election when President Biden did his address to the nation.

And, you know, watching someone who has served our country for 50 years in that particular moment, and seeing this person who has never once let go of hope in the face of so much adversity, over many times in his life, to me, was extremely inspiring.

And one of the things that he said that day was that setbacks are unavoidable, but giving up is unforgivable. And, you know, I think all of us need to take a deep breath when things, when the world is not unfolding the way we would like to see it unfolding.

And it’s definitely a put your oxygen mask on first moment, where we have to, you know, make sure you’re safe and solid and stable. But, you know, really, would we forgive ourselves if we gave up the things that we care about, for serving our communities and building a better tomorrow for our country and for the world?

None of that has changed. And so, it is a time to build our strength and draw on our hope so that we can keep doing the work.

Dean Galea: Dr. Prabhakar, thank you for a really interesting conversation, but perhaps much more importantly, for everything you do and you’ve done over so many years for the country, for science, for technology, I’ve enjoyed our conversations, I’ve learned a lot from you. Thank you.

Director Prabhakar: Thank you for all the work you all do here.

Dean Galea: Thank you

Director Prabhakar: And for what your students are gonna do out in the world.

Dean Galea: That’s exactly what we’re-

Director Prabhakar: Thanks for having me.

Dean Galea: Looking forward to. Thank you.

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