The Regulatory Frontier: Battling Red Tape at Scale

频道: Naval
视频: https://www.youtube.com/watch?v=c6aemQE3RSw
原文语言: en
统计: 共 32 轮 · 硬件专家 7 · Naval 13 · Max 4 · 医疗专家 5

[0:00] 硬件专家

We started building these kind of like software frameworks. It allows two engineers to design an entire jet engine.

我们开始搭建这类软件框架，能让两个工程师就设计出一整台喷气发动机。

[0:05] 硬件专家

There's no like startup that builds hardware collaboration tools that can sell you anything anymore. Even spreadsheets are kind of cooked.

现在已经没有哪家创业公司还能卖给你硬件协作工具了，连 spreadsheet 这种东西都基本玩完了。

[0:12] 硬件专家

The closer that our products get to being like a single block of coalently bonded matter, the better they'll be.

我们的产品越接近一整块共价键结合（covalently bonded）的物质，它就越好。

[0:16] Naval

Intelligence is an unalloed good. You always want more intelligence. If you fall behind on your ability to generate software, you fall behind on the ability to generate everything.

智能是纯粹的好（unalloyed good），你永远会想要更多的智能。一旦你在生成软件的能力上落后了，你就会在生成一切的能力上落后。

[0:24]

The software still needs hands. Like it's going to be smarter than us. But if it can't make things then those are real real boundaries.

软件仍然需要双手。它会比我们聪明，但如果它造不出实物，那这些就是实打实的边界。

[0:31]

I mean humans are becoming verifiers right?

我的意思是，人类正在变成验证者（verifier），对吧？

[0:34] 硬件专家

One of the things we see related to the regulatory is it massively reduces change aversion and improves iteration. So to give you an example like let's let's say you're going to go certify an airplane. One of the zillions of things you have to do is prove that it can withstand a lightning strike. And the the regulatory documentation for the test plan for such a thing stretches on for say 200 pages. And what you would classically do is hire a let's be honest not super bright engineer who's willing to be there monkey at keyboard writing 200 pages of regulatory compliance documentation. And it takes a couple months and and by the way if you change the airplane now you want to cry because there's another like two months of rework of this like wrote kind of regulatory compliance documentation. And what we found is you we can build a rag that will enable us to basically prompt our way through all of that work you know in let's call it minutes. The first order effect is oh you save a lot of time. the the the second order effect is if you change the specification of the airplane uh it now takes you know minutes not months. So you can actually be willing to change and the third order effect is you can now you know basically get rid of the not very great engineers and have a small number of really creative ones that can iterate rapidly because the cost of change goes down and in a certain sense like the entire regulatory burden which really hurts the ability to iterate drops away.

在监管这块，我们看到的一件事是：它能大大降低对变更的抵触，并提升迭代速度。举个例子，假设你要去给一架飞机做认证，你必须做的成千上万件事里有一件，是证明它扛得住雷击。而这种测试方案的监管文档动辄写满 200 页。过去你会怎么做？说白了就是雇一个不太聪明、但又愿意当‘键盘苦力’的工程师，让他去写这 200 页合规文档，写上几个月。而且更要命的是，你一旦改了飞机设计，简直想哭，因为又得花差不多两个月去返工这些照本宣科的合规文档。我们发现，可以搭一个 RAG，让我们基本上靠提示（prompt）几分钟就把这些活全干完。一阶效应是：哦，省了大量时间。二阶效应是：你改飞机规格时，现在只要几分钟而不是几个月，所以你才真的愿意去改。三阶效应是：你现在基本可以不要那些不怎么样的工程师，只留一小撮真正有创造力的人快速迭代，因为变更成本降下来了。某种意义上，原本严重拖累迭代能力的整个监管负担，就此消失了。

[1:59] Max

I think that this is a really unsold story in AI right now. I think the consensus in Silicon Valley is that like regulation sucks. Like any like we want to go faster, we want to realize this amazing future. We want abundance. We want just like prosperity and stuff that slows down that future is just kind of to be avoided. And certainly I think we've overregulated. We've made it impossible to build stuff. It's just like it's totally crazy what goes into getting building any type of thing in a lot of places either physical or otherwise. But you know like a lot of the regulations themselves are not the problem. Like if you've actually read a lot of these things like like having non smog choked cities is great. Being able to swim in like many rivers is great. Like having like a lot of these things were progress. The problem is that it is really difficult for humans to deal with understanding and complying with this. And that every time you have to exchange a letter with the government, you wait months. And if you could take a lot of the things that we've learned and kind of make them like totally frictionless, that would actually pretty cool. And I think that um that I think is an under an undersold story. in in AI right now.

我觉得这是当下 AI 里一个被严重低估的故事。硅谷的共识是监管很烂——我们想跑得更快，想实现那个美好的未来，想要丰裕（abundance），想要繁荣，凡是拖慢这个未来的东西都该被绕开。我当然也认为我们监管过度了，把造东西这件事搞得几乎不可能。在很多地方，无论造实体的还是别的什么，要把任何一种东西建起来，背后那套流程简直疯了。但你知道吗，很多监管本身并不是问题。如果你真去读过这些条文，会发现：城市不被雾霾呛着，挺好的；很多河里能游泳，挺好的；这里头很多东西都是进步。问题在于，对人类来说，理解并遵守这些规定实在太难了。而且每次你要跟政府打一次书面往来，就得等上好几个月。如果我们能把已经学到的很多东西做得完全没有摩擦，那其实会相当酷。我觉得这在当下的 AI 里是个被低估的故事。

[3:00] Max

Yeah. Until the regulators start spewing tokens back at us and then you start getting huge amounts of documents from the regulators that you have to comply and it's agent on agent wars. But

对，直到监管方也开始朝我们喷 token，然后你就会从监管方那儿收到海量你必须遵守的文件，变成 agent 打 agent 的战争。不过——

[3:09] 硬件专家

but that's basically what we have now.

但我们现在基本上就是这个状态。

[3:12] Max

Yeah. But but there is a fair fight. Yeah.

对，但这是一场公平的较量。是的。

[3:14] 硬件专家

I'd argue that's an improvement from where we are now. Like one of the terrible things right now is if you're going to build anything physical, you have to get a building permit. It's like you're guilty until proven innocent. And the worst thing I've that we've run into is the fire department because they have like the moral impremature of, you know, people pulling people out of burning buildings. And yet what they actually do is just like screw with your design for buildings for months. And I, you know, if we could replace the fire marshall with with an agent that would critique your your building plan quickly,

我倒觉得这比我们现在的处境是个进步。现在最糟糕的一件事是：你要建任何实体的东西，都得先拿到建筑许可。这就像有罪推定、得自证清白。我们碰到过最糟的就是消防部门，因为他们头顶着一道道德光环——你懂的，是从着火的楼里把人救出来的那群人。可他们实际干的事，就是拿着你的建筑设计反复折腾你好几个月。如果我们能把消防队长换成一个 agent，让它快速地点评你的建筑方案——

[3:45]

um, even even if it's feedback was overdone, it would be massively better than the delays that exist today. When Max was talking about this potentially being a good thing to have all this regulation, my my head went to the things that make agents successful is uh humans or other agents setting up the right testing guard rails. Uh a lot of people are really excited about SLGO. I don't know if you guys have played with that or like Ralph loops where you tell the model go do this and this is your exit criteria. Well, I'm telling Blake go make us all supersonic. your exit criteria is that you've complied with all of these regulations. So there's totally a world where we say like the regulations are great. They're like our testing, our test suite. As long as this p passing these tests one does not incurring contradictions and the regulations are actually reasonable, etc. Like they're actually an awesome guard rail to have. Otherwise, we would be shipping slop directly into into the air.

嗯，哪怕它的反馈有点过头，也比今天这种拖延要好太多了。刚才 Max 说这一大堆监管搞不好是件好事，我脑子里立刻想到的是：让 agent 成功的关键，是由人或别的 agent 给它设好正确的测试护栏。很多人对 SLGO 特别兴奋，不知道你们玩过没有，还有那种 Ralph loop——你告诉模型去干这件事，这就是你的退出条件。那好，我告诉 Blake：去把我们都搞成超音速，你的退出条件是你已经满足了所有这些监管要求。所以完全可以有这样一个世界：我们说监管很棒，它们就像是我们的测试套件（test suite）。只要能通过这些测试、不引入矛盾、而且这些监管本身确实合理，等等，那它们其实就是一道极好的护栏。不然的话，我们就会把垃圾（slop）直接送上天了。

[4:42] Naval

Yeah. But this is going to turn into a red queen's race, right? They're going to have agents. We're going to have agents. I think we might have better agents, which is good, as opposed to have to do human versus human. But if anything, their cycle time, their response time may get lower. Like the app store is drowning in spam. I'm sure the patent office right now is drowning in spam. And so these agencies, they're going to be slow adopters of AI. They're going to get DDoSed, right, by clever entrepreneurs just overloading them with documents. It's possible that the approval time for this stuff might extend out as this suddenly get flooded. It creates the opportunity to um I think really shift the model, the regulatory model. Imagine if we drove around a city the way we build things today. Before you could go anywhere, you'd have to write a plan up, ship it to some regulator, you know, and your plan would have to specify we're going to take such and such a route and we're going to drive this speed limit. We're going to use our blinker and we're going to stop at every stop sign and we're never going to run a red light, blah blah blah blah blah. And then 3 months later, you get back critique. It's like, well, we think you should like drive on this other street. And eventually you get to prove well you can go drive somewhere. It's insane. You can never go anywhere. And yet that is absolutely the way we build physical infrastructure in this country. It's guilty until proven innocent. And and what we should actually do is make more of these things enforcementbased rather than preapproval based. I mean I don't know. I mean I I don't want to be under too much. Like if I ship a medical device to a lot of people there needs to be it's like there's unknowns there. It's like we were responsible. We did clinical trials. who reported all the data. But

对，但这会变成一场红皇后赛跑（Red Queen's race），对吧？他们会有 agent，我们也会有 agent。我觉得我们的 agent 可能更强，这是好事，总好过人对人。但话说回来，他们的周期时间、响应时间反而可能会变得更长。App Store 现在被垃圾内容淹没了，专利局现在我敢肯定也被垃圾淹没了。所以这些机构会是 AI 的慢采用者，他们会被精明的创业者用海量文件灌爆、DDoS 掉。完全有可能这些东西的审批时间反而会被这突如其来的洪流拉长。但这也创造了一个机会，我觉得可以真正改变这套模式、改变监管模式。想象一下，如果我们开车上街是用今天造东西的那套方式来搞的：你去任何地方之前，都得先写一份计划，寄给某个监管者，你的计划得写明我们要走某某路线、开多少时速、会打转向灯、每个 stop sign 都会停、绝不闯红灯，等等等等。然后三个月后你收到点评：嗯，我们觉得你应该改走另一条街。最后你好不容易才证明自己可以去某个地方开车。这太疯了，你永远哪儿都去不了。可这恰恰就是我们这个国家建实体基础设施的方式——有罪推定。我们真正该做的，是把这里面更多的东西改成基于事后执法（enforcement-based），而不是基于事前审批（pre-approval）。我是说……我也不确定，我也不想太放飞。比如我要把一个医疗器械卖给一大群人，那确实得有……那里头是有未知数的。就好比，我们是负责任的，我们做了临床试验，把所有数据都上报了。但是——

[6:12] Naval

Max, this is this is why there's so little innovation in medical right now because the FDA approval process is a nightmare. Uh in fact, the two biggest advancements in tech in Silicon Valley in the last decade, AI and before that crypto, they're both in the math domain because that's the last unregulated domain. And when they started regulating frontier models and started regulating GPUs, that stops as well. You know, Peter Teal laments about how there's no innovation in the physical domain. what's been held back by just the huge regulatory barriers and you can always find a scare version like you know vaccine or medical like famous ones right but the regulations spread everywhere the technicals are everywhere and there's all these different contradictory regulatory bodies you saw how uh was it SpaceX they got sued first for for not having enough I forget what it was migrants or refugees or whatever but they're not allowed to hire them by government regulation on the other side because they're not citizens this is not like logical code that has to compile in one place. These are made up random regulations all over the place. You might comply with one state, you violate another state, you violate federal over here, you annoy this guy over here, that guy chooses to prosecute one out of 50 people who are his friend. It's it's very arbitrary. It's very capricious.

Max，这正是为什么现在医疗领域几乎没什么创新，因为 FDA 的审批流程就是一场噩梦。事实上，硅谷过去十年里科技上最大的两项突破——AI，以及在那之前的 crypto——都在数学领域，因为那是最后一块没被监管的领域。等到他们开始监管前沿模型、开始监管 GPU，这个也会停下来。你知道 Peter Thiel 老在感叹实体领域为什么没有创新，就是被巨大的监管壁垒卡住了。你总能找到一个吓人的反例，比如疫苗、医疗那些有名的案例，对吧，但监管其实无处不在，技术细节也无处不在，而且还有一堆互相矛盾的监管机构。你看到过——是 SpaceX 吧？他们先是被告，理由是没招够……我忘了是移民还是难民什么的，可另一边政府监管又规定他们不许招这些人，因为他们不是公民。这根本不像那种必须在一个地方编译通过的逻辑代码，这些是到处胡乱编出来的监管。你可能遵守了一个州的，就违反了另一个州的，又违反了这边的联邦规定，还惹毛了那边的某个人，而那个人会专挑 50 个人里跟他是朋友的那一个去起诉。这非常任意，非常反复无常。

[7:21] 硬件专家

And and moreover, like the idea that this makes like things safer, I think it's just a complete mythology. Like just watch, you know, watch watch Boeing as an example. They certified the 737 Max, which had a single sensor that had complete authority over the nose up, nose down attitude of that airplane. No intern is dumb enough to think that's a good idea. And yet, it got all the way through the certification system. This stuff doesn't actually make us safer. It just makes us slower. Well, I mean, there's definitely dysfunction here. I mean, I think that some of this makes us safer in the sense that the NRC makes us safer, which is that their job was to make sure that nuclear energy was safe. They did this by permitting zero plants until I think like a year ago since the 70s. It will be perfectly safe if we never build any of it. And I want to be really clear that I'm on the side of deregulation in on a lot of this. I agree with Blake that a lot of this can be done a lot more efficiently. But I also think it's a little too dismissive just to say it's like oh this is like the FDA or like even it's it's in the reg it's in the agencies in general. And the problem is deeper to the degree that when the if the FDA approves 10 really important drugs, they don't get any credit for that. One patient dies and they get hauled before Congress and yelled at. And so they have very negatively biased incentives here. And I I think the reality is is that this is reflective of the beliefs of the American people. There's this trade-off here between the perception of risk taken in human subjects research and the rate at which we get new medicines. And it is absolutely true that if we move faster on this, we would learn. It's totally asymmetric. And I think you're totally right, Max. If you approve a bad thing, your career is over. If you block a good thing, nobody notices, right? So it so it creates this asymmetric slowdown. And I think this is um I think that is the most important problem to solve in the regulatory state.

而且更进一步说，认为这套东西能让我们更安全，我觉得纯粹是个神话。你就看 Boeing 这个例子：他们给 737 Max 做了认证，而这架飞机只靠一个传感器就能完全决定机头朝上还是朝下的姿态。再蠢的实习生也不会觉得这是个好主意，可它居然一路通过了整个认证体系。这套东西其实并没让我们更安全，只是让我们更慢。当然，这里头确实有失灵的地方。我是说，我觉得其中有些东西确实让我们更安全，就像 NRC（核管会）让我们更安全一样——它的职责是确保核能安全，而它做到这一点的办法是：从上世纪 70 年代到大约一年前，一座电厂都不批。要是我们永远不建任何核电，那当然绝对安全。我想说得非常清楚：在这很多事情上，我是站在放松监管这一边的，我同意 Blake 说的，很多事情可以做得高效得多。但我也觉得，仅仅一句『哦，这就是 FDA，或者说就是这些机构本身的问题』，未免太轻描淡写了。问题更深：如果 FDA 批准了 10 款真正重要的药，他们一点功劳都得不到；可一旦有一个病人死了，他们就会被拉到国会去挨骂。所以他们的激励是严重偏向负面的。我觉得现实是，这其实反映了美国民众的信念。这里存在一个权衡：一边是人们对在人体试验中所冒风险的观感，另一边是我们拿到新药的速度。绝对没错，如果我们在这方面跑得更快，我们会学到更多，这完全是不对称的。Max，我觉得你说得太对了：你批准了一个坏东西，你的职业生涯就完了；你拦下了一个好东西，没人会注意到，对吧？所以它造成了这种不对称的拖慢。我觉得这是监管体制里最重要、最该去解决的问题。

[9:02] Max

But but this is a very deep problem because it is this is where the voters are like and we we go and poll some of the stuff that we're working on in the future to understand kind of like where where the American people are on it. And if you push too hard on this, like there there are all kinds of ways you could work around it. You go to prosper. There's all kinds of ways to try to go faster. But if you're seen as being a bad actor, then you're rejected from the society that we live in. That is the thing that you need an answer for, which is deeper than just saying like, "Oh, well, we need regulatory reform."

但这其实是个特别深层的问题，因为这正是选民所在的位置。我们会针对一些未来要推进的政策去做民调，想搞清楚美国人到底站在哪一边。如果你在这件事上逼得太狠，确实有各种绕过去的办法——你可以去 Prosper，可以想各种办法跑得更快。但一旦你被外界视为坏人(bad actor)，你就会被我们所在的这个社会拒之门外。这才是你真正需要给出答案的东西，它比单纯说一句'我们需要监管改革'要深得多。

[9:31] Naval

You you have a deep point there, Max, which is uh it's the voters, right? Yeah.

Max，你这句话点得很深——根子其实在选民身上，对吧？是啊。

[9:35] Naval

This where the citizens are. Like we like to blame politicians. You'll see us on X all the time, right? When people are like, "Oh, this politician, that politician, you a politician." It's like they're elected. They're voted. Majority vote, right? This is where the people literally are. That's the package. That's the bundle they've chosen. And you may not like this constantiation. But if you were to remove this one, something very similar would take its place because the voters would just vote him right back in. And I think culturally it's very hard for most people to understand what we lost, what we missed, right? So for example, like France, you know, there's a French entrepreneur on X lamenting that 57% of GDP gets sucked up by the government and so you can't create companies. But to the average French citizen, that's not visible. They don't notice what they're missing. They just know they're slightly poorer than the US. The economist just did a little piece on uh economist is finally coming back around to being capitalists after 30 years. And they just did a little piece on how the US is outstripping everybody and growing faster and getting bigger. But then they immediately turn around and say, well, it's because of the oceans, because of natural resources, everything but capitalism, right? They don't want to say the dirty sea word. uh because you know for some reason all of these all of these uh magazines became Marxists at some point um but they can't they can't envision or imagine what could have been if we had just been a little more lazare a little more open

问题出在公民本身。我们老爱怪政客，你天天能在 X 上看到——大家就是'哎呀这个政客、那个政客，你这个政客'。可他们是选出来的呀，是投票投上去的，多数票，对吧？这恰恰就是人民真实站着的位置，这就是他们选出来的那个'套餐'、那个打包的组合。你可能不喜欢这套配置，但就算你把这个人换掉，顶替他的也会是个非常类似的人，因为选民转头又会把他选回去。而且我觉得，从文化层面看，大多数人很难理解我们到底失去了什么、错过了什么。比如说法国吧，X 上有个法国创业者在感慨：57% 的 GDP 都被政府抽走了，所以你根本没法创办公司。可对普通法国人来说，这是看不见的，他们感觉不到自己错过了什么，只知道自己比美国人稍微穷一点。《经济学人》最近还出了篇小文章——这家杂志熬了三十年，总算又重新认同资本主义了——他们写了篇小文，讲美国怎么把所有人都甩在身后、增长更快、体量更大。可话锋一转他们马上又说：哦那是因为有海洋、因为有自然资源，反正什么原因都行就是不提资本主义，对吧？他们就是不愿意说出'资本主义'这个脏字。不知怎么的，这些杂志在某个时间点全变成马克思主义者了。可他们就是没法去设想、去想象：如果我们当初稍微更放任(laissez-faire)一点、更开放一点，本来能成就什么样的局面。

[10:49] Naval

so I would love to see a true experiment among the 50 states you know different regulations different tax structures not because right now the federal tax structure and federal regulations dominate everything but imagine you know you could go to some small state if you had cancer and you could try every drug that everyone was cooking up in caviat mtor and you got to do your research and blah blah blah but this is known as the experimental zone um same way for drones same way for well aircraft is a little harder because you got to cross a lot of areas but

所以我特别想看到 50 个州之间来一场真正的实验——不同的监管、不同的税制。当然，现在联邦税制和联邦监管压倒了一切。但想象一下，假如你得了癌症，你可以跑到某个小州去，把所有人正在捣鼓的新药全都试一遍——比如在某个 caveat 框架下，你自己做研究等等——这就是所谓的'实验特区'。无人机也可以这么搞，飞行器要难一点，因为它得跨越很多区域，不过……

[11:16] 医疗专家

and do you think there's something magical in there the notion of like innovation zones because we have we have a huge like nimi problem right uh but if you if you create like you know opt-in yimi zones they create some experimentation framework and by definition it happens where people are consenting and you can try different rules or no rules or different ways of enforcing or you know innocent until proven guilty and then see what actually happens and what are the innovation consequences and what are the safety consequences and then then the successes can spread but I mean to Naval's to Naval's point an innovation zone would not solve the problem in drug discovery um there so there's the right to try act passed a little while ago we've had this pathway called single patient IND for a lot longer than that um the FDA like if if your doctor calls the FDA and says hey I want to give this my patient an approved drug they give over 99% of those over like they approve over 99% of those. They can even grant them over the phone. Um the problem is that in order to dose a patient, you still need clinical grade drug and the only entity with that is typically the IP owner who's in the middle of running a clinical trial. Like they're investing hundreds of millions of dollars into like making this thing. And the problem is that the FDA, they'll draw an adverse inference if something bad happens to your patient who's probably really sick to begin with. And that's going to be seen as a property of the drug which is global, not related to your innovation zone. And so there's kind of two problems. One is you need to get the IP owner to give you some of your drug which they're not going to do. And then you need to prevent the global regulator from casting doubt on what might happen with their clinical trial if they give you some.

那你觉得'创新特区'这个概念里有没有什么神奇之处？因为我们有个巨大的 NIMBY 问题，对吧。但如果你搞那种选择性加入的 YIMBY 特区、建立某种实验框架，那按定义来说，它就发生在人们自愿同意的地方，你就可以在里头试不同的规则、或者干脆没规则、或者不同的执法方式，或者'疑罪从无'，然后看看实际会发生什么、创新带来什么后果、安全又带来什么后果，成功的做法再向外扩散。但是，回到 Naval 刚才那个点——创新特区其实解决不了新药研发的问题。早些时候通过了一个'尝试权法案'(Right to Try Act)，更早之前我们还有个叫'单一患者 IND'的通道。FDA 那边，如果你的医生打电话给 FDA 说'嘿，我想把这个已获批的药给我的病人用'，他们 99% 以上都会批，甚至能在电话里当场批准。问题在于，要真的给患者用药，你还得有临床级别的药，而通常唯一拥有这种药的，就是正处在临床试验当中的 IP 持有方——人家可是砸了几亿美元在搞这个东西。而麻烦的是，FDA 会做'不利推断'(adverse inference)：万一你那个本来就病得很重的患者出了什么事，这件事就会被算成药本身的属性，而这是全局性的，跟你那个创新特区一点关系都没有。所以这里其实有两个问题：一是你得让 IP 持有方分一点药给你，人家根本不会给；二是你还得防止这个全局监管者因为给了你一点药，就反过来对人家的临床试验结果产生疑虑。

[12:47] Naval

How would you I mean I don't know your field. How would you address that in medicine?

那你会——我不太懂你这个领域——你在医学上会怎么解决这个问题？

[12:51] 医疗专家

Oh well, I mean that in particular I mean this is just like a very inside baseball. I think the FDA has to be prohibited from drawing adverse inferences across different users of a capsit, for example. There's these like a bunch of specific ways that you could really accelerate innovation with a relatively light regulatory touch by just um preventing this this kind of paranoia from driving our decisions.

嗯，这个嘛，具体来说这就是很'圈内'的细节了。我觉得必须禁止 FDA 在某个产品的不同使用者之间做不利推断。有那么一批很具体的办法，只要用相对轻的监管力度，光是阻止这种偏执心态主导我们的决策，就真的能大大加速创新。

[13:12] 医疗专家

Is there anything better than the FDA out there? Like what are we benchmarking these regulators against or is it not an interesting question because we don't have everyone follows the FDA. So I'll give two two expansions of that. The first is um Europe which is not really better than the FDA but they have a different system in that they've got these these notified bodies which are basically private businesses that are blessed by their host governments to certify things whether this is trains or planes or medical devices and the notified body system uh creates slightly better incentives at the review layer because they can hire people. They can grow there's competition among the notified bodies. they themselves have to be compliant with the conditions placed by their host governments for certification. But that means that they can there can be many thousands more reviewers than you might have in the US. The second thing I'll say is there actually is one approved getting paid implantable BCI today which is in China and the CFDA is thinking for itself. And they really do have a system that I think is going to give us a run for our money if we're not if we're not careful. they they they handle it very differently.

外面有没有比 FDA 更好的东西？我们到底是拿这些监管机构跟什么去对标？还是说这压根不算个有意思的问题，因为大家其实都跟着 FDA 走？我从两个方向展开说一下。第一是欧洲——欧洲其实并不比 FDA 强，但他们的体系不一样：他们有所谓的'指定机构'(notified bodies)，本质上是一些私营企业，得到所在国政府的认可去做认证，不管是火车、飞机还是医疗器械。这套指定机构体系在审评层面带来的激励稍微好一点，因为它们可以招人、可以扩张，机构之间还存在竞争；同时它们自己也得满足所在国政府为认证设定的条件。但这意味着，审评人员的数量可以比美国多出成千上万。第二点我想说，今天其实已经有一款获批的、可以收费植入的脑机接口(BCI)了，就在中国。CFDA 是在独立思考的，他们那套体系，我觉得如果我们再不当心，是真能跟我们一较高下的。他们处理这事的方式很不一样。

[14:16] Naval

How do they handle it?

他们是怎么处理的？

[14:18] 医疗专家

I mean the costs to bring a drug to market or a device to market are just much lower. I mean you can try things in humans and you can try things on market like the so the problem the one of the things that I've spent a lot of time recently thinking about is like 20 years ago we were buying far fewer laptops and phones. Each one was much more expensive. Now there's they're cheaper. There's far more of them. We buy more of them. The total spending has gone up. This is great. stock prices of things like Qualcomm and Samsung and Apple are way up. Everybody's happy. They're using kind of the excess wealth generated by the phones and laptops to buy the phones and laptops. Um, this doesn't happen in healthcare. In healthcare, because you've got this reimbursement mechanism in the way where there's this kind of enterprise sale happening, the bucket of money that we use to buy healthcare is basically fixed. It is not increasing as there is more stuff that is producing better healthcare outcomes like we see in technological growth industries. And so this means that the rate of spending on healthcare grows at roughly the rate of of growth of tax receipts. And so if let's say that like AI is booming and there's major advances that are happening and 2 years from now we're spending 10 times as much on AI as we are now, this could be great. But if in 2 years we're spending 10 times as much on healthcare, this would be a catastrophe. And this is fundamentally at odds with being a technological growth industry. And so as time goes on and there's more things to spend money on that extend and improve the quality of life for patients like we can restore vision to people go blind in their 80s. We might be able to extend life in like far past where it's been before. We can restore capability to patients that are older and in worse condition. But like how do you pay for that? There's kind of this like omni problem in healthcare which is all really related to the same problem which is it's just too expensive to bring these things to market. And that's what China is getting at. The way out of this is not singlepayer or some revision to health to health insurance. It's to bring down the costs so that someone can buy this with a credit card finance maybe like a car worst case. And to do that we have to make it cheaper to bring these things to market. And China's doing that that will allow them to sell these things for $10,000 on $100,000. There's no private market in healthcare. And because there's no private market, what was the analogy people make sometimes? Like imagine instead of going to restaurants and paying, you would basically go to all the restaurants and then at the end of the month you would send all the receipts and all the bills to your insurer or to the government and they would reimburse you. Well, there'd be a line outside every good restaurant, every bad restaurant, you know, would be available. Um the weights would be terrible. The product wouldn't improve. You're basically running a small communist society inside a larger capitalist society. And that's what we're doing in healthcare. It's also what we're doing on roads, which is why we have traffic. Like, it's the exact same situation on roads. It's why there's, you know, there's no variable pricing for getting on the highway. It's why it's always clogged. If you want to step on the third rail of healthcare for for a moment, think about this healthcare plan. Tell me what's wrong with it. Right? Imagine that the first 20% of your uh annual income was your healthcare deductible. Doesn't matter like if if you're broke and homeless, it's zero. If you're rich, you know, it's millions of dollars. Uh, but whatever your annual income is, the first 20% is your healthcare deductible. And then the rest is paid by the government, the insurance system up to the usual caps that they have today. You would create a private market pretty quickly. And so like in dental and plastic surgery and sort of a lot of optional medical procedures, you would actually get a competitive situation. You get improvement. Like if you look at optometry, you know, with LASIC, you look at dental with like veneers and uh braces and all that stuff and kind of all the dental surgery stuff that they do. Or if you look at plastic surgery, like those fields do seem to be advancing because they're private payers. They have people who are, you know, voting with their money. So we need to do some equivalent of that in the normal healthare system. But people lose their minds. They don't want to think one step ahead. They're like, "No, no, no. Well, what about the broke person?" Well, the broke person has no income. So you they're like, "Well, 20% is too much for some people. Okay, you can put some deductible in there, but generally if you don't have some private market where people are paying a lot of the times for what are medical procedures, you're just not going to get this feedback loop that you're talking about. You're not going to get this ability to spend more money into the system right now. Like very wealthy people can't spend voluntarily into the system, but the prices aren't anywhere. The rate cards aren't anywhere. The system's not designed for it. It's like if you go shopping for medical care and you want to pay out of your pocket, sometimes they'll quote you a price that's 10x what they charge the insurance company.

我是说，他们把一款药或一款器械推向市场的成本就是低得多。你可以在人身上做试验，也可以在市场上试。我最近花了很多时间在想这么一件事：20 年前我们买的笔记本和手机少得多，每台都贵得多；现在它们更便宜了、数量多得多、我们买得也更多，总开支反而上去了——这是好事。Qualcomm、三星、苹果这类公司的股价都涨上天了，大家都很开心。手机和笔记本创造出来的财富盈余，又被拿去买更多手机和笔记本。可这种循环在医疗里压根不会发生。在医疗里，因为中间卡着这套报销机制——本质上是一种'企业对企业'(enterprise sale)的销售模式——我们用来买医疗的那桶钱基本是固定的。哪怕有越来越多能带来更好健康结果的东西冒出来，这桶钱也不会像技术增长型行业那样增加。结果就是，医疗开支的增速大致只能跟着税收的增速走。打个比方：假如 AI 正在爆发、不断有重大突破，两年后我们在 AI 上的花费是现在的 10 倍，这可以是天大的好事；可如果两年后我们在医疗上的花费变成 10 倍，那就是一场灾难。这从根本上就和'技术增长型行业'是矛盾的。所以随着时间推移，能延长寿命、提升患者生活质量的东西越来越多——我们能给八十多岁失明的人恢复视力，也许能把寿命延长到前所未有的程度，能让年纪更大、状况更差的患者恢复机能——可你拿什么去付这笔钱？医疗里有个'万恶之源'式的问题，归根结底都是同一个：把这些东西推向市场实在太贵了。这正是中国在攻克的点。出路不是单一支付方(single-payer)，也不是对医保做什么修修补补，而是把成本降下来，让人能用信用卡就买得起，最坏情况下像买车那样分期。要做到这点，我们就得让'把东西推向市场'这件事变得更便宜。中国正在做这件事，这会让他们能把原本要卖 10 万美元的东西，10000 美元就卖出去。医疗里根本不存在私人市场。正因为没有私人市场——大家有时会打那个比方来着？想象一下，你吃饭不是去餐厅当场付钱，而是把所有餐厅都跑一遍，到月底把所有的收据、账单寄给你的保险公司或者政府，让他们给你报销。那结果就是每家好餐厅门口都排长队，每家烂餐厅也照样开着、随便进，等待时间惨不忍睹，产品永远不会进步。你这等于是在一个更大的资本主义社会内部，跑了一个小型的共产主义社会。这正是我们在医疗里干的事。我们在道路上干的也是同一件事，所以才会堵车——道路上的情况一模一样，所以上高速没有浮动定价，所以它永远堵得水泄不通。如果你愿意碰一碰医疗这根'高压线'，那来想想下面这个医保方案，告诉我它哪里不对。想象一下：你年收入的头 20% 是你的医疗免赔额(deductible)。如果你身无分文、流落街头，那就是零；如果你很有钱，那可能就是好几百万美元。但不管你年收入多少，头 20% 都是你的医疗免赔额，超出这部分的就由政府、由保险系统来付，封顶线还是用今天那一套。你会很快催生出一个私人市场。在牙科、整形外科以及一大堆可选医疗项目上，你真的会形成有竞争的局面，会有进步。你看眼科里的 LASIK 激光手术，看牙科里的贴面、牙套以及那些牙科手术，再看整形外科——这些领域看起来确实在进步，因为它们靠的是自费的私人付款方，靠的是那些用钱投票的人。所以我们得在常规医疗体系里搞出某种等价的机制。可一提这个大家就炸了，他们根本不愿意往前多想一步，只会说'不不不，那穷人怎么办？'——可穷人没有收入啊，对他来说那就是零。他们又说'对有些人来说 20% 太多了'，行，那你可以放一点别的免赔额进去；但总的来说，如果你没有一个让人们大量自费支付各种医疗项目的私人市场，你就根本得不到我们刚说的那个反馈循环，也就根本没法把更多的钱投进这个系统里。比如现在，就算是极有钱的人也没法主动往系统里花钱，因为价格根本不公开、价目表(rate card)根本不存在，整个系统压根就不是为这个设计的。这就好比你去自费看病、想自己掏腰包，他们有时候报给你的价，是给保险公司开价的 10 倍。

[18:38] Naval

Have you heard Sid's story from GitLab?

你听过 GitLab 那位 Sid 的故事吗？

[18:42] Naval

Do you know Sid?

你认识 Sid 吗？

[18:44] Naval

So he was uh I mean he had a massively successful IPO then was diagnosed with a rare cancer and has achieved has lived way past the prognosis has really taken it into his own hands. I think he went from kind of he did frontline chemo and then there was one alternative that was available. He exhausted it and the doctors were like, "We've got nothing for you." Since I think like six or seven companies have come out of it, there's now 20 or 30 drugs in his escalation ladder. He's still alive. Um years later,

他当年 IPO 大获成功，之后却被诊断出一种罕见癌症，结果他活得远远超出了医生的预后判断，是真的把命运攥在了自己手里。我记得他先是做了一线化疗，然后还有一种可选疗法，他把那个也用尽了，医生就跟他说'我们没招了'。从那以后，我记得有六七家公司是因为他这事冒出来的，现在他那个'升级阶梯'(escalation ladder)上已经有二三十种药了。他到现在还活着，已经好多年过去了。

[19:13] Naval

he's doing great. I saw him the other day and he he basically created his own like personalized medicines and uh treatment plan.

他状态好得很。我前几天还见过他，他基本上是给自己量身打造了一套个性化药物和治疗方案。

[19:20] 医疗专家

Yeah, there's there's a handful of these anecdotes that I've heard now. I it is really clear to me that at the high end if you just kind of have like you're not dealing with insurance you have the resources you're like I want the full toolbox of modern science outcomes are possible that that like your normal like if you go and ask your doctor like oh what will happen if I do this they will just start shouting and throwing things but it is clear that that much that like that crazy things are possible at the high end and I think that this type of like end of one medicine is actually going to end up being a really rich source of research for understanding how to build more translatable things.

是啊，这类故事我现在已经听过好几个了。我现在看得特别清楚：在最顶端那一层，只要你不用去跟保险纠缠、你有资源、你就是想要'现代科学的整套工具箱'，那是真有可能出现各种结果的。换成普通人——你要是去问你的医生'我要是这么干会怎样'，他们多半会冲你大喊大叫、摔东西。但很清楚的是，在最顶端那一层，那些疯狂的事情是真能实现的。我觉得这种'n 等于 1'(end-of-one)的医疗，最后其实会成为一个极其丰富的研究富矿，帮我们搞清楚怎么去构建出更可推广、可迁移的东西。

[19:54] Naval

It requires a ton of agency from the patient in a moment where they're at their weakest, which is pretty uh ironic. My friend passed away from cancer and like last thing he wanted to do was research n equals one medicine uh cuz he was just, you know, like like dying by the week. But this is where AI should really shine and come up with the right solutions and democratization of like what can you actually do when you find yourself in that situation. It it's it's kind of crazy how few people get access to this just from a knowledge perspective, not just monetarily speaking.

这需要患者拿出巨大的能动性(agency)，偏偏是在他们最虚弱的时刻，这点挺讽刺的。我有个朋友死于癌症，他当时最不想做的事就是去研究什么'n 等于 1'的医疗——因为他正一周一周地往下垮、就快不行了。但这恰恰是 AI 真正该大放异彩的地方：拿出对的解决方案，把'你身处那种境地时究竟还能做什么'这件事民主化。说真的，能接触到这些东西的人少得离谱，而且这还不只是钱的问题，光是从知识层面看就少得可怜。