Bioethics Forum Essay
Science in the Biden White House: Eric Lander, Alondra Nelson, and the Legacy of Lewis Thomas
At least symbolically, science has replaced populism in the White House. During the Trump administration the portrait in the Oval Office to the left of the Resolute Desk was the populist Andrew Jackson. It has been replaced by one of Ben Franklin. According to the Washington Post, Franklin — along with a moon rock placed on a nearby shelf — is intended to convey President Biden’s deep interest in science and to remind Americans what it can accomplish. At a more substantive level Biden has nominated geneticist Eric Lander, president and founder of the Broad Institute, to be his science advisor and head of the White House Office of Science and Technology (OSTP), elevating the position for the first time to cabinet rank.
Lander’s appointment is a good omen for an evidence-based approach to policy after the wilderness years of the Trump Administration. But it is also a departure from the roster of those who have traditionally served in the position. Physicists and engineers have dominated as Science Advisors, not life scientists. During the Cold War, the predominant scientific concern was about preventing Armageddon.
No less a life scientist than the late Lewis Thomas, famed author of The Lives of a Cell and the New England Journal of Medicine feature “Notes of a Biology Watcher”, acknowledged this need. Buried in a long endnote in his The Youngest Science: Notes of a Medicine Watcher, Thomas wrote of his service on the President’s Science Advisory Committee (PSAC), having been appointed by President Johnson.
Worried about the “immediate hazard of nuclear warfare,” Thomas shared his preference for physicists: “If it were up to me, I would leave off the medical people and biologists, or perhaps have them there as a small minority, and I would load them up with the best physicists in the United States.” In that moment, physicists, not physicians, were needed to avoid nuclear catastrophe and pursue arms control. We doctors might call that primary prevention.
But times have changed. Today the primary threat is not nuclear annihilation (though it remains possible). Instead, it is the devastation of a brutal pandemic and the menace of mendacity when it comes to public faith in science. Given this, I suspect that Thomas would have been delighted that President Biden nominated Lander, a fellow biologist able to bring science to the public and into policy. He might also have something to suggest to the OSTP as they respond to the Covid-19 pandemic.
When Thomas served on the PSAC, the OSTP’s predecessor, the President’s science advisor asked him to lead a working group to reconceptualize medical technology. Although written half a century ago, their analysis provides a useful heuristic to frame our current pandemic response.
Thomas and his colleagues characterized three classes of technology. The first is “genuine high technology” predicated on knowledge of basic disease mechanisms. These are definitive interventions which eliminate disease. In the context of the Covid response, this would include vaccine development, genomic surveillance of errant Covid-19 variants, and rapid swap-out technologies to modify mRNA vaccines to boost immune response to new viral strains. None of this would have been possible without basic knowledge of the SARS-CoV-2 genome and the translational ability to manufacture mRNA that coded for the spike receptors on the surface of the virus.
To maximally utilize this technology, and potentially adapt the vaccine to emerging strains like those encountered in the United Kingdom and South Africa, we need to do more than to continue to invest in basic science. We also must devote greater resources to the local public health infrastructure to track the epidemiology and genomics of the pandemic. The United States is woefully behind in these capabilities compared to other countries.
In a prescient 1983 essay in Health Affairs, written at the dawn of the HIV/AIDs epidemic, Thomas spoke of the need to engage local health clinics in research. He urged research collaborations with local public health offices to complement their clinical activities. We should heed his advice today and provide the investments necessary for the federal government to partner with local officials to collect epidemiological data necessary for evidence-based policy. For too long the nation’s public health infrastructure has been starved for resources. The OSTP can change that, bringing clear benefits now and in future pandemic responses.
Thomas described a second tier of mitigating “halfway technologies.” These interventions hold the line until a definitive cure becomes available or a disease can be eradicated. Think of the iron lung for the treatment of polio as a halfway technology which managed patients until the Salk and Sabin vaccines were developed. In the context of Covid-19, halfway technologies would include developing, repurposing, and assessing, drugs like monoclonal antibodies, the antiviral remdesivir, and the steroid dexamethasone. None of these drugs cure Covid-19 but they get us part of the way there in reducing disease burden.
Public health measures are also halfway technologies. While they don’t eliminate the virus, they can flatten the curve, preserve hospital capacity and decrease overall mortality. Central to these halfway technologies are broad access to testing, as well as masking and social distancing, still our most effective measures short of mass vaccination.
Third are nontechnological measures for those who will die of Covid-19. Their passing should be as comfortable and humane as possible. When Thomas wrote palliative care was not yet in the vernacular, but I imagine that pain and symptom management was what he had in mind.
The OSTP is poised to recommend an investment in palliative care to reduce patient and family burden. Central to this effort will be strategies to provision hospitals with adequate personal protective equipment to liberalize family visits. Epidemiological studies should track the impact of family visits on disease spread, bereavement, and the correlative emotional toll on clinicians asked to step in for absent family members at life’s end. At this juncture in the pandemic, no one should die alone. It’s bad for patient, families, and practitioners, and is inhumane.
Although Thomas was pretty certain that his panel’s report “was filed and probably forgotten,” history has been kind to his mid-century analysis. But there is more to Thomas’s œuvre than his reflections on government service. He won the National Book Award for Lives of a Cell and left behind a treasure trove of essays linking the sciences and the humanities. Many are worthy of Montaigne, one of his heroes.
Given the breadth of his scholarship, were he to comment on the pandemic, I suspect Thomas would be deeply attuned to questions of health equity and the ethical choices that often implicitly inform “objective” science policy. While we need to use our heads when crafting science policy, we also must probe our hearts to ensure that our choices reflect our best values.
To that end, I would imagine that Thomas would have been especially delighted that President Biden also broke precedent in selecting a sociologist to serve as deputy director of the OTSP. Biden chose Alondra Nelson, president of the Social Science Research Council, a professor at Princeton, and a Hastings Center fellow, to share her expertise. Nature noted it was an inspired choice and I agree. Professor Nelson’s insights, along with a new Presidential Commission for the Study of Bioethical Issues, could help address questions about inequity, structural racism, and vaccine hesitancy, all of which have contributed to the deaths of over 460,000 Americans. These are complex challenges that will require scientific, sociologic, and ethical reflection.
On my first day of medical school, I met Lewis Thomas for the first and last time. He gave the incoming class at Cornell our first lecture. His essays inspired me in college when I dreamt of becoming a doctor. So, I brought my copy of The Youngest Science to class and hoped he would sign it. He was as gracious in person as he was eloquent in print. As I write this essay, the signed volume is at my side. It is one of my prized possessions, especially during this pandemic.
Joseph J. Fins, M.D., M.A.C.P., F.R.C.P., is the E. William Davis Jr. M.D. Professor of Medical Ethics and a Professor of Medicine at Weill Cornell Medical College, Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law and a Visiting Professor of Law at Yale Law School and a member of the Adjunct Faculty at the Rockefeller University. He is a Hastings Center Fellow and member of the Center’s Board of Trustees.