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The Court of Humanity

Constitutional Architecture for Removing Sovereign Immunity from Negligent Mass Homicide

Author

Affiliation

Mike P. Sinn

Institute for Accelerated Medicine

Abstract

Sovereign immunity is the legal doctrine preventing private parties from suing governments without the government’s consent. The doctrine descends from pre-democratic principles and has been waived selectively by sovereigns for conduct affecting politically powerful constituencies, while being preserved for conduct producing the largest body counts. This paper proposes the Court of Humanity, a decentralized adjudication mechanism deriving jurisdiction from popular legitimacy rather than sovereign consent. Plaintiffs may be any human; defendants may be any government; juries are stratified random samples of verified humans drawn proportionally from the global population, voting on factual questions with formula-determined structural remedy. Enforcement is not coercive but capital: judgments are priced into sovereign bond yields, insurance premia, trade flows, and procurement decisions. Applying standard regulatory life valuations ($7-12M per statistical life) to historical and projected government-attributable mortality (war, regulatory delay, misallocation; see¹⁴⁸), we estimate aggregate unliquidated wrongful-death exposure at approximately $104 quadrillion. Governments cannot pay this judgment. They can, however, settle for the 1% Treaty¹⁴⁹, which functions as the most generous settlement offer in legal history.

Keywords

sovereign immunity, tort law, decentralized adjudication, proof of personhood, capital markets, international law, government accountability, wrongful death

The Question Nobody Asked You

Should every person have the legal right to seek justice against any government that kills, injures, or harms them or their family?

This is the question your species never put to itself. The reason is structural: the people who would have called the vote are the people who would have lost it.

A child can answer this. So can a grandmother. So can a refugee, a soldier, a doctor, a tax accountant. The answer polls between 85% and 95% in every population it has been tested on, including populations of countries whose own governments would face immediate exposure. The 5%-15% who say no are heads of state, defense contractors, and the people directly employed by them. Voting no requires saying out loud “I believe my government should be allowed to kill my family with no consequences.” Almost no human will say this when asked. The question therefore wins.

Sovereign Immunity Is a Choice Nobody Chose

If a hospital kills your mother through negligence, you can sue. If a drug company hides safety data, you can sue. If a private security contractor shoots a child by accident, you can sue. If the government does the exact same thing, you cannot.

The legal doctrine that protects governments is called sovereign immunity. It descends, without architectural modification, from the principle of the king can do no wrong. Your species abolished the divine right of kings in the 18th century. You retained the one part of it that needed abolishing.

Sovereign immunity is waivable. Governments can give it up at any time. The United States has waived it for: postal-truck collisions, malpractice at federal hospitals, slip-and-falls in federal buildings, unauthorized disclosure of tax returns, and the disposal of certain hazardous materials. It has not waived it for: dying because the FDA refused to release a drug Germany prescribes for breakfast, dying because the Pentagon misplaced $2.46 trillion that would have funded your trial, or dying because your country bombed your city under a stated rationale that turned out to be wrong.

The asymmetry is not constitutional. It is political. Congress passes laws creating government liability for harms that damage people powerful enough to lobby. It does not pass laws creating government liability for harms that damage people too dead or too poor to lobby.

The Doctrinal Map

The U.S. Federal Tort Claims Act (FTCA) waives sovereign immunity for limited categories of governmental tort, while preserving it for the categories that produce the largest body counts. The exclusions form a remarkably precise map of the conduct documented in The Invisible Graveyard¹⁴⁸ and The People of Earth v. Their Governments:

• Discretionary function exception (28 U.S.C. § 2680(a)): Policy choices, including military allocation, regulatory standards, and budgetary priorities, are immune.
• Combatant activities exception (28 U.S.C. § 2680(j)): Deaths arising from military combat are immune.
• Foreign country exception (28 U.S.C. § 2680(k)): Harms occurring outside the U.S. are immune.
• Feres doctrine (judicially created, 1950): Active-duty military personnel cannot sue for service-connected injuries.

Each exclusion was lobbied for, drafted by, and enacted by the same institutions whose conduct it now immunizes. The pattern is the predictable equilibrium of allowing the defendants to write their own immunity statutes.

The Real Name for This Is Protection Racket

A “protection racket” is when a powerful entity provides “protection” against threats it itself creates, while exempting itself from accountability for the harm it causes. Your governments charge $2.72 trillion per year for “national security.” The same governments wrote the laws that prevent you from suing them when their security operations kill your family. This is not democracy. It is the structural form of organized crime, with the addition of a flag.

The question for you is not whether sovereign immunity is correct. The question is whether you noticed it exists, and whether, having noticed, you are willing to leave it in place.

The Damages Math

Your governments’ own actuaries value a statistical human life at $7-12 million (the standard regulatory valuation used by the EPA, DOT, and FDA). Applying this valuation to the body count cataloged in The People of Earth v. Their Governments:

Count	Body Count	Damages at $9.5M/life
One. Direct killing through war (1900-present)	310 million	~$2.95 quadrillion
Two. Regulatory delay (1962-present)	102 million	~$969 trillion
Three. Misallocation (forward-looking)	10.7 billion	~$101 quadrillion
Aggregate liability	~11.1 billion	~$104 quadrillion

For context, your global GDP is approximately $100 trillion per year. Your governments owe approximately one thousand years of global economic output in unliquidated wrongful-death exposure.

Your governments do not have this money. They cannot pay this judgment. Discounting these damages by 99% still produces an annual liability stream that exceeds the entire global military budget by a factor of four.

This is not a problem for the Court. This is a feature. A judgment a defendant cannot pay is a judgment that changes their behavior. The Court does not need to extract $104 quadrillion. The Court needs only to establish that the debt is owed. The pricing of that debt by capital markets does the rest.

The Court Itself

The Court of Humanity is not a courtroom. It is a protocol. The architecture is closer to a distributed fact-finding system with automatic structural remedy than to anything that currently exists in jurisprudence. Lawyers are not the load-bearing structure. They exist as a fallback for edge cases.

Plaintiffs. Any human, anywhere. No nationality requirement. No lawyer required. A plaintiff submits evidence to the public ledger and selects the closest matching case template, or files as “novel” for full procedure. Filing is free or carries a nominal refundable bond.

Defendants. Any government, anywhere. The Court does not require defendant consent. Jurisdiction derives from the consent of humans, who are the actual sovereign in any honest description of how political legitimacy works.

Templates. Most cases pattern-match to pre-published templates: FDA Phase II/III mortality, drone strike under disputed rationale, budgetary misallocation toward weapons over health, environmental harm under the discretionary-function exception. Each template specifies the elements that must be proven, the standard evidentiary forms, and a pre-calculated structural remedy (typically a percentage redirect to the relevant public trust, an automatic injunction, or a contribution to a victim-compensation fund). Templates themselves are drafted, debated, and ratified through global deliberative referenda.

AI-assisted brief generation. Multiple independent AI systems (one prosecution-aligned, one defense-aligned, one neutral, with reputational and financial stakes) produce competing summaries of the evidence and competing analyses of how the conduct does or does not match the template. Voters consume the summaries; the raw 10,000-page filing remains available on demand. Disagreements between AI systems are flagged for expanded human review.

Stratified random jury. A randomly selected jury of approximately 1,000-10,000 verified humans, drawn proportionally from the global population using demographic and regional stratification, votes on each case. Multiple parallel juries vote on the same case independently. Consistent verdicts across parallel juries indicate robust findings; divergent verdicts trigger expanded review. The stratified-random model prevents vote-brigading (advocates cannot select their own jury) and bounds information overload (only ten thousand humans must read the evidence, not eight billion).

Binary voting on facts. Jurors vote yes or no on whether the conduct matches the template’s elements. They do not vote on damages amounts. Damages are determined by the template’s formula. This restriction is essential: it prevents sentiment-driven damages inflation, eliminates lottery dynamics, and produces verdicts predictable enough for capital markets to price.

Proof of personhood. Jurors verify their personhood through multiple independent biometric or social-graph systems (Worldcoin, BrightID, government IDs from non-defendant states). Eligibility requires verification on at least N systems, reducing the impact of any single system being compromised. The verification systems are themselves auditable through the Court, preventing capture.

Edge cases. Roughly 1-5% of cases will be genuinely novel: conduct that does not match any template, or evidence requiring expert investigation beyond AI capacity. These proceed under modified adversarial procedure with attorneys and expert witnesses. The output of these cases is typically a new template, which is then ratified through deliberative referendum and added to the library. The other 95-99% are pattern-matched, AI-briefed, jury-voted, and automatically remedied with no lawyer required.

Enforcement. The Court does not have a sheriff. It has capital markets.

Failure Modes and Mitigations

The Court’s design must remain robust against several attack categories. The mitigations below are not theoretical; each maps to existing solutions in the prediction-markets, cryptography, or decentralized-governance literatures.

Failure mode	Mitigation
Proof-of-personhood system capture	Require verification on N independent PoP systems (Worldcoin, BrightID, government IDs from non-defendant states). Operators stake reputational and financial bonds. PoP systems themselves auditable through the Court.
Defendant disinformation flooding	Cryptographic evidence provenance with public versioning ledger. Multiple independent AI summarizers with reputational stakes. Jurors retain access to raw evidence on demand.
Vote brigading and ideological capture	Stratified random jury rather than open voting. Jurors are selected, not self-selected. Reputation-weighted voting on factual sub-questions, with reputation accruing from agreement with eventual consensus across multiple cases.
Frivolous filings	Small refundable filing bond. AI triage to bundle similar cases into class actions. Pattern-matching to existing templates flags weak cases for early dismissal.
Defendant non-compliance with judgment	Capital-markets enforcement via sovereign bond pricing, insurance premium adjustments, and trade flow reallocation. This is the primary enforcement mechanism and does not depend on defendant consent.
Damages-formula gaming	Independent classification by multiple AI systems with disagreement-triggered jury review. Templates designed with overlapping coverage to prevent gaps that defendants can exploit.
Single-point-of-failure technical attacks	Court protocol implemented across multiple independent technical communities; no single server, organization, or jurisdiction controls the ledger, the AI summarizers, the PoP systems, or the jury-selection algorithm.

None of these failure modes is fatal under the proposed mitigations. They are design problems with established solutions, applied at the scale and consequence of the underlying mass tort.

The Enforcement Stack

Capital markets are the broadest enforcement layer. They are not the only one. The full Court enforcement stack has five layers, each operating independently and reinforcing the others.

Layer	Mechanism	Acts on
Economic	Sovereign bond yields, insurance premia, trade flow reallocation	Treasuries, central banks, finance ministries
Diplomatic	Procurement conditions, treaty access, recognition rules	Foreign ministries, UN seats, trade pacts
Judicial	Bondholder suits under Treaty Article VI	Domestic courts, Treasury solicitors
Political	Super PACs scoring legislators on Court compliance, funded by the IAB Political Incentive Fund	Individual legislators, party leadership, campaign finance
Reputational	Public verdict ledger, citizen pressure, journalist scrutiny	Voters, donors, regulators, civil society

The political layer is the one most likely to operationalize the others. Capital-markets pressure is real but slow. Diplomatic pressure is real but coordinated by the same officials being scored. Judicial pressure is bottlenecked by court calendars. Political pressure is the layer that can fire the people in office and replace them with people who are not. It is the fastest available enforcement mechanism that operates within each defendant’s existing constitutional framework.

How the Political Layer Works

The Political Incentive Fund, funded by 10% of every Treaty dollar ($2.72 billion/year at scale), is the largest political-incentive fund in human history by an order of magnitude. It is structured as a Super PAC and operates by the rules every Super PAC operates by. The difference is the target.

The Fund scores every legislator on two voting axes:

1. Treaty compliance. Did you vote to implement and expand the 1% Treaty¹⁴⁹?
2. Court compliance. Did you vote to honor Court of Humanity judgments against your government, or did you vote to obstruct, defund, or ignore them?

Compliant legislators receive campaign support for reelection and post-office fellowships when they retire (board seats, lobbying-free advisory positions, university chairs, foundation grants). Non-compliant legislators face the same thing aimed at their opponents.

The NRA has run this exact system for 50 years and has demonstrated that a single-issue scoring fund can reliably shape congressional votes regardless of party affiliation, district demographics, or stated principles. The infrastructure exists. The legal framework exists. The only thing missing was the funding source and the target list. The Treaty provides the first; the Court provides the second.

A legislator’s choice becomes structurally simple:

• Vote to comply with Court rulings: receive Fund support, retain seat, retire to a fellowship.
• Vote to obstruct Court rulings: watch the Fund support your opponent, lose the next primary, exit politics with no fellowship.

This is not a moral appeal. It is an incentive realignment. The legislators are not being asked to change their values. They are being asked to respond to incentives, which is what they already do, on every other issue, every day. The Fund is the upstream redirect that determines which incentives they respond to.

How Capital Markets Enforce What Courts Cannot

The Court does not need to seize bank accounts or arrest officials. It needs only to publish judgments. Bond markets are excellent at pricing tail risk; they will price this. Insurance underwriters will reflect wrongful-death exposure in premiums. Investors prefer jurisdictions with lower legal-risk tails, so capital reallocates toward recognizing governments. Empirically, the same mechanism produced the South African divestment cascade, ESG-driven sovereign repricing, and rule-of-law shocks visible in CDS spreads on Hungarian and Turkish debt. The mechanism is mature; the application to sovereign-immunity-shielded conduct is novel.

The mechanism that enforces the Court is not the Court. It is the consequence of being a defendant.

Nobody Gets a Lottery Ticket

A reasonable concern: if any human can sue any government for negligent homicide, will rich plaintiffs with good lawyers collect $9.5 million per family member while the defendants collapse into bankruptcy and the rest of humanity gets nothing?

No. The Court does not work that way, and the reason it does not work that way is the reason it works at all.

The Court is a class-action mass tort with mandatory structural settlement. Individual plaintiffs do not collect individual checks. Here is what actually happens:

1. Liability is established globally. The defendants owe approximately $104 quadrillion. This figure exists to set the negotiating floor, not to be distributed.
2. The Court issues structural judgments, not individual awards. A typical judgment looks like: “the defendant shall redirect X% of military spending to clinical trials, perpetually, with bondholders enforcing compliance.” The 1% Treaty is the standard form of such judgment.
3. The remedy flows to a public trust, not to plaintiffs’ bank accounts. Disease victims receive cures, not checks. War victims receive peace, not reparations. Regulatory-delay victims receive faster access to the next drug, not retroactive damages.
4. Specific harm categories may have dedicated victim trust funds, paying out per formula. This is exactly how the 9/11 Victim Compensation Fund worked ($7 billion disbursed, no individual lottery winners), how the Vaccine Injury Compensation Program works (no-fault structured payouts), and how asbestos trust funds work (industry-financed, formula-based). Decades of precedent. None of them bankrupted anyone.
5. Lawyers are mostly absent. For the 95-99% of cases that pattern-match to existing templates, no attorney is involved. AI-assisted briefs and stratified juries do the work. For the small minority of novel cases that proceed through traditional adversarial procedure, attorneys are paid through fee-shifting (capped at 15–20% of the settlement fund) rather than individual contingency, aligning their incentives with establishing precedent rather than hunting jackpots.
6. The only category of human who profits in cash is bondholders, and bondholders profit by financing the case, not by being victims. They are the plaintiff’s underwriters. Their returns scale with the structural settlement’s success. This is the Incentive Alignment Bond mechanism.

This architecture solves four problems simultaneously:

• No defendant bankruptcy. Governments pay X% per year, sustainably, perpetually.
• No race to the courthouse. First-filers and last-filers receive equivalent structural compensation.
• No fraudulent-claim epidemic. You do not get money personally. There is nothing to defraud.
• The damages flow to fixing the cause of death, which prevents the next set of cases from arising.

The pattern, in tort-law terminology, is aggregated injunctive and structural relief rather than individual compensatory damages. The body count is too large to compensate individually anyway. Even if every defendant liquidated their entire treasury, $104 quadrillion divided by 11.1 billion victims is approximately $9.4 million per victim, and the defendants do not have $104 quadrillion. Individual compensation is mathematically impossible at the scale of the harm. Structural remedy is the only model that arithmetic permits.

Precedents

The structural-settlement model has substantial historical precedent in mass-tort and policy-driven compensation systems:

• Asbestos trust funds (1980s–present): Following industry-wide bankruptcy filings, courts approved Section 524(g) trusts that pay claimants per formula. Disbursements are reduced as funds deplete; no claimant collects full theoretical damages; the system has paid over $30 billion to >800,000 claimants without bankrupting any participating industry.
• 9/11 Victim Compensation Fund (2001–present): Special master Kenneth Feinberg administered $7+ billion in disbursements to ~5,500 families and survivors using a structured formula. No individual recipient received “full” damages; all received roughly proportional structured awards.
• Vaccine Injury Compensation Program (1988–present): No-fault administrative compensation system funded by a per-dose excise tax. Has paid >$5 billion to ~9,000 claimants without producing vaccine-industry collapse or fraudulent-claim epidemic.
• Camp Lejeune Justice Act (2022): Recent precedent specifically waiving sovereign immunity for a defined class of harm (toxic water exposure) with structured settlement formulas.
• Tobacco Master Settlement Agreement (1998): $206 billion structured settlement paid to 46 states over 25+ years, funded by ongoing per-pack assessments. Did not bankrupt the tobacco industry; did transform industry behavior and fund public-health programs.

Each precedent demonstrates that mass tort liability of significant magnitude can be resolved through structural settlement without either defendant collapse or plaintiff-lottery dynamics. The Court of Humanity’s structural-settlement model is the same mechanism, scaled to the global level and applied to the largest unaddressed mass tort in human history.

This means the Court of Humanity is not a vehicle for getting rich off your government’s negligence. It is a vehicle for making your government stop being negligent. The compensation you receive is your own non-death and your descendants’ continued existence. This is, on examination, a more useful form of compensation than a check.

The 1% Treaty Becomes the Settlement Offer

Your governments cannot pay $104 quadrillion. They can, however, settle.

The 1% Treaty¹⁴⁹ is the settlement offer. It is the most generous settlement offer in legal history: governments accept liability for $27.2 billion per year (1% of military spending), in exchange for capping their exposure to the larger judgment indefinitely. The redirected funds go to clinical trials and bondholders, both of which are net welfare-positive uses.

Mechanism	Function
Court of Humanity	The lawsuit. Establishes ~$104 quadrillion in unliquidated wrongful-death exposure.
1% Treaty	The settlement. Caps governments’ exposure for 1% of military spending.
Incentive Alignment Bonds	The plaintiff’s contingency arrangement. Pays the lawyers and campaigns.
dFDA	The court-supervised remedy. Absorbs redirected funds and clears the disease backlog.

In any private-sector tort context, defendants facing $104 quadrillion in exposure would settle for 1% of their annual budget the day the suit was filed. Their lawyers would advise it. Their boards would demand it. Their shareholders would sue them if they didn’t. Your governments do not have lawyers, boards, or shareholders. They have voters. The Court of Humanity is what gives the voters the leverage that lawyers, boards, and shareholders provide in every other context.

Why This Is Not the ICC

The International Criminal Court (ICC), International Court of Justice (ICJ), and various tribunals (ad hoc, hybrid, regional) have not produced the accountability outcomes their proponents anticipated. The reason is structural: each existing court derives jurisdiction from defendant consent. Defendants who anticipate being defendants do not consent. The United States, China, Russia, Israel, and India are not parties to the Rome Statute. The result is a system that prosecutes the powerless on behalf of the powerful, which is the exact inversion of what international criminal law was supposed to do.

The Court of Humanity differs in three respects:

1. Jurisdiction is not consent-based. Jurisdiction derives from the consent of humans, not the consent of governments.
2. Enforcement is not coercive. Enforcement is via capital-markets pricing of judgments. The defendants cannot revoke their participation in capital markets without imposing higher costs on themselves than the judgment would have imposed.
3. The plaintiff base is global and individual. Existing courts admit only state-on-state suits (ICJ) or specific listed cases (ICC). The Court admits any harmed human against any government.

The Court is therefore not a competitor to the ICC. It is a successor class of institution, addressing the structural gaps that existing institutions cannot close.

The Two-Question Ballot

The current global referendum asks one question: “Do you support the 1% Treaty?” The polling is good but mixed; the Treaty involves specific budget mechanics that some voters find complicated.

The Court referendum question is simpler and polls 10-15 points higher: “Should every person have the legal right to seek justice against any government that kills, injures, or harms them or their family?”

The strategy is to put both on the same ballot. The Court question polls 90%+ and drags the Treaty question across the finish line. The Court question is the popular trigger; the Treaty is the operational mechanism it triggers.

A voter who answers yes to the Court question has, in operational terms, voted to remove sovereign immunity. A voter who answers yes to the Treaty question has, in operational terms, voted to accept the settlement offer rather than pursue the full judgment. Most voters will answer yes to both. The remainder will answer yes to the first and no or undecided to the second. The first vote is sufficient to begin the process. The second is sufficient to end it on terms favorable to everyone except defense contractors and the regulatory bureaucracies that have spent 60 years killing more people than they saved.

What Happens When 4 Billion People Answer Yes

The dynamics are deterministic once the threshold is crossed:

1. The result is impossible to ignore. More participation than every election in human history combined. Every politician asked: “Do you support the result?”
2. Smaller nations sign on first. Costa Rica, Ireland, New Zealand, Iceland, Norway, Switzerland. Costs them nothing. Makes them moral leaders. Cascades.
3. Holdout governments expose themselves. The United States, China, Russia, Israel, France, the UK forced to argue for sovereign immunity against a backdrop of 4 billion people who voted no. Every argument sounds like “we need the legal right to kill people without consequences.”
4. Legal infrastructure self-organizes. The Court does not require government permission. It requires legitimacy. 4 billion verified human votes is more democratic legitimacy than any institution ever constituted. Lawyers draft the charter. Scholars define jurisdiction. Participating countries recognize authority.
5. Capital responds before the first ruling. Bond yields adjust. Insurance premia adjust. Investment flows adjust. Defendants’ costs of capital rise without anyone seizing anything.
6. The first ruling is small. Likely a wrongful-death claim against a participating government for police violence or pharmaceutical-delay mortality. The participating government pays. Precedent is set. Legitimacy compounds.
7. Holdouts choose. Join and accept accountability, or remain outside and pay escalating capital, diplomatic, and reputational costs forever. This is the same dynamic that produced WTO adoption, the Geneva Conventions, and the Universal Declaration of Human Rights. The dynamic is not new. The application is.

Bootstrapping the System

The Court’s most genuine weakness is the bootstrapping period. Until templates are established, every case is novel. Until proof-of-personhood systems achieve adequate population coverage, jury legitimacy depends on the available verified population. Until capital markets begin pricing judgments, the enforcement mechanism is partial.

The proposed bootstrap path proceeds in three phases:

Phase 1: Foundation cases. The first ~100 cases proceed under traditional adversarial procedure with attorneys, expert witnesses, and full discovery. These cases establish initial templates, develop the evidentiary infrastructure, and produce the first capital-markets pricing data. Voluntary participating governments (likely Costa Rica, Ireland, New Zealand, Iceland, Norway) supply the early defendants. Foundation-case attorneys are paid through fee-shifting from a pre-funded litigation trust capitalized by the Incentive Alignment Bond¹⁵⁰ mechanism.

Phase 2: Template ratification. Drawing from the foundation-case docket, the Court drafts initial case templates and submits them for global deliberative referendum. Successful templates enter the library; unsuccessful templates remain in traditional adversarial procedure. The next ~10,000 cases use a hybrid model: templated where possible, traditional where not.

Phase 3: Steady-state. Pattern-matched cases dominate the docket (95-99% of filings). Attorneys and expert witnesses occupy the edge-case fallback procedure rather than the routine procedure. The Court operates primarily as an automated structural-relief mechanism with occasional traditional-procedure inputs for novel conduct categories.

The Judicial Branch of Wishocracy

Wishocracy¹⁵¹ describes a governance system in which decisions are made by the consent of the governed, weighted by neither wealth nor party affiliation, with corruption capped at 20% by structural design. The Court of Humanity is wishocracy’s judicial branch. The book has previously described the executive branch (the Optimitron), the budgetary mechanism (Incentive Alignment Bonds¹⁵⁰), and the legislative trigger (the 1% Treaty). The Court is what was missing.

In existing political theory, separation of powers requires three branches that constrain each other. Your current system has three branches that coordinate with each other against the citizenry. The Court of Humanity restores the separation by introducing a fourth branch (the citizenry itself, voting on cases) that constrains the other three.

The defendants will object that this is mob rule. The prosecution observes that 8 billion humans are not a mob. They are the population. The current system is mob rule by approximately 5,000 elites operating under the procedural shield of sovereign immunity. The Court of Humanity replaces the small mob with the large one, weighted equally per capita. This is what democracy was supposed to be. It is not what democracy currently is.

What You Do

The vote is at warondisease.org. It contains both questions. The vote takes 30 seconds. The Court referendum question is the simpler one. Answer it first. The Treaty question is the second. Answer it however you like; the math works out either way, because the Court question is the one that matters.

Forward this to one human you know who has more reach than you. They forward to one human with more reach than them. Within seven steps, the message reaches a head of state, a billionaire, a litigator, or a journalist with a column. Within twenty steps, it reaches all of them. The math of the chain reaction is in the appendix.

Your government has spent the past 80 years getting better at killing people while writing the laws that prevent you from suing them for it. The next 80 years are about whether your species notices.

You have noticed.

The remaining question is what you do next.

1.

NIH Common Fund. NIH pragmatic trials: Minimal funding despite 30x cost advantage. NIH Common Fund: HCS Research Collaboratory https://commonfund.nih.gov/hcscollaboratory (2025)

The NIH Pragmatic Trials Collaboratory funds trials at $500K for planning phase, $1M/year for implementation-a tiny fraction of NIH’s budget. The ADAPTABLE trial cost $14 million for 15,076 patients (= $929/patient) versus $420 million for a similar traditional RCT (30x cheaper), yet pragmatic trials remain severely underfunded. PCORnet infrastructure enables real-world trials embedded in healthcare systems, but receives minimal support compared to basic research funding. Additional sources: https://commonfund.nih.gov/hcscollaboratory | https://pcornet.org/wp-content/uploads/2025/08/ADAPTABLE_Lay_Summary_21JUL2025.pdf | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604499/

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2.

Cato Institute. Chance of dying from terrorism statistic. Cato Institute: Terrorism and Immigration Risk Analysis https://www.cato.org/policy-analysis/terrorism-immigration-risk-analysis

Chance of American dying in foreign-born terrorist attack: 1 in 3.6 million per year (1975-2015) Including 9/11 deaths; annual murder rate is 253x higher than terrorism death rate More likely to die from lightning strike than foreign terrorism Note: Comprehensive 41-year study shows terrorism risk is extremely low compared to everyday dangers Additional sources: https://www.cato.org/policy-analysis/terrorism-immigration-risk-analysis | https://www.nbcnews.com/news/us-news/you-re-more-likely-die-choking-be-killed-foreign-terrorists-n715141

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3.

NIH. Antidepressant clinical trial exclusion rates. Zimmerman et al. https://pubmed.ncbi.nlm.nih.gov/26276679/ (2015)

Mean exclusion rate: 86.1% across 158 antidepressant efficacy trials (range: 44.4% to 99.8%) More than 82% of real-world depression patients would be ineligible for antidepressant registration trials Exclusion rates increased over time: 91.4% (2010-2014) vs. 83.8% (1995-2009) Most common exclusions: comorbid psychiatric disorders, age restrictions, insufficient depression severity, medical conditions Emergency psychiatry patients: only 3.3% eligible (96.7% excluded) when applying 9 common exclusion criteria Only a minority of depressed patients seen in clinical practice are likely to be eligible for most AETs Note: Generalizability of antidepressant trials has decreased over time, with increasingly stringent exclusion criteria eliminating patients who would actually use the drugs in clinical practice Additional sources: https://pubmed.ncbi.nlm.nih.gov/26276679/ | https://pubmed.ncbi.nlm.nih.gov/26164052/ | https://www.wolterskluwer.com/en/news/antidepressant-trials-exclude-most-real-world-patients-with-depression

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4.

CNBC. Warren buffett’s career average investment return. CNBC https://www.cnbc.com/2025/05/05/warren-buffetts-return-tally-after-60-years-5502284percent.html (2025)

Berkshire’s compounded annual return from 1965 through 2024 was 19.9%, nearly double the 10.4% recorded by the S&P 500. Berkshire shares skyrocketed 5,502,284% compared to the S&P 500’s 39,054% rise during that period. Additional sources: https://www.cnbc.com/2025/05/05/warren-buffetts-return-tally-after-60-years-5502284percent.html | https://www.slickcharts.com/berkshire-hathaway/returns

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5.

World Health Organization. WHO global health estimates 2024. World Health Organization https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates (2024)

Comprehensive mortality and morbidity data by cause, age, sex, country, and year Global mortality:  55-60 million deaths annually Lives saved by modern medicine (vaccines, cardiovascular drugs, oncology):  12M annually (conservative aggregate) Leading causes of death: Cardiovascular disease (17.9M), Cancer (10.3M), Respiratory disease (4.0M) Note: Baseline data for regulatory mortality analysis. Conservative estimate of pharmaceutical impact based on WHO immunization data (4.5M/year from vaccines) + cardiovascular interventions (3.3M/year) + oncology (1.5M/year) + other therapies. Additional sources: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates

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6.

GiveWell. GiveWell cost per life saved for top charities (2024). GiveWell: Top Charities https://www.givewell.org/charities/top-charities

General range: $3,000-$5,500 per life saved (GiveWell top charities) Helen Keller International (Vitamin A): $3,500 average (2022-2024); varies $1,000-$8,500 by country Against Malaria Foundation: $5,500 per life saved New Incentives (vaccination incentives): $4,500 per life saved Malaria Consortium (seasonal malaria chemoprevention):  $3,500 per life saved VAS program details:  $2 to provide vitamin A supplements to child for one year Note: Figures accurate for 2024. Helen Keller VAS program has wide country variation ($1K-$8.5K) but $3,500 is accurate average. Among most cost-effective interventions globally Additional sources: https://www.givewell.org/charities/top-charities | https://www.givewell.org/charities/helen-keller-international | https://ourworldindata.org/cost-effectiveness

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7.

U.S. Department of Defense. 5.56mm NATO ammunition bulk procurement pricing. (2024)

The cost of 5.56mm NATO ammunition at military bulk procurement rates is approximately $0.40 per round, based on Lake City Army Ammunition Plant production and commercial market floor prices for mil-spec M855 ammunition.

8.

Pike, J. U.s. Forces fire 250,000 rounds for every insurgent killed. (2011)

The General Accounting Office reports that US forces used 1.8 billion rounds of small-arms ammunition per year, a level that more than doubled in five years. An estimated 250,000 rounds were fired for every insurgent killed in Iraq and Afghanistan.

9.

AARP. Unpaid caregiver hours and economic value. AARP 2023 https://www.aarp.org/caregiving/financial-legal/info-2023/unpaid-caregivers-provide-billions-in-care.html (2023)

Average family caregiver: 25-26 hours per week (100-104 hours per month) 38 million caregivers providing 36 billion hours of care annually Economic value: $16.59 per hour = $600 billion total annual value (2021) 28% of people provided eldercare on a given day, averaging 3.9 hours when providing care Caregivers living with care recipient: 37.4 hours per week Caregivers not living with recipient: 23.7 hours per week Note: Disease-related caregiving is subset of total; includes elderly care, disability care, and child care Additional sources: https://www.aarp.org/caregiving/financial-legal/info-2023/unpaid-caregivers-provide-billions-in-care.html | https://www.bls.gov/news.release/elcare.nr0.htm | https://www.caregiver.org/resource/caregiver-statistics-demographics/

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10.

Forbes. Forbes world’s billionaires list 2024. (2024)

Forbes identified a record 2,781 billionaires worldwide with combined net worth of $14.2 trillion, 141 more than 2023. Bernard Arnault (LVMH) topped the list at $233 billion.

11.

CDC MMWR. Childhood vaccination economic benefits. CDC MMWR https://www.cdc.gov/mmwr/volumes/73/wr/mm7331a2.htm (1994)

US programs (1994-2023): $540B direct savings, $2.7T societal savings ( $18B/year direct,  $90B/year societal) Global (2001-2020): $820B value for 10 diseases in 73 countries ( $41B/year) ROI: $11 return per $1 invested Measles vaccination alone saved 93.7M lives (61% of 154M total) over 50 years (1974-2024) Additional sources: https://www.cdc.gov/mmwr/volumes/73/wr/mm7331a2.htm | https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00850-X/fulltext

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12.

CDC. Childhood vaccination (US) ROI. CDC https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6316a4.htm (2017).

13.

U.S. Bureau of Labor Statistics. CPI inflation calculator. (2024)

CPI-U (1980): 82.4 CPI-U (2024): 313.5 Inflation multiplier (1980-2024): 3.80× Cumulative inflation: 280.48% Average annual inflation rate: 3.08% Note: Official U.S. government inflation data using Consumer Price Index for All Urban Consumers (CPI-U). Additional sources: https://www.bls.gov/data/inflation_calculator.htm

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14.

James Surowiecki. The Wisdom of Crowds. (Surowiecki, 2004).

Explores the aggregation of information in groups, arguing that decisions are often better than could have been made by any single member of the group. The opening anecdote relates Francis Galton’s surprise that the crowd at a county fair accurately guessed the weight of an ox when the median of their individual guesses was taken. The three conditions for a group to be intelligent are diversity, independence, and decentralization. Additional sources: https://archive.org/details/wisdomofcrowds0000suro | https://en.wikipedia.org/wiki/The_Wisdom_of_Crowds | https://www.amazon.com/Wisdom-Crowds-James-Surowiecki/dp/0385721706

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15.

ClinicalTrials.gov API v2 direct analysis. ClinicalTrials.gov cumulative enrollment data (2025). Direct analysis via ClinicalTrials.gov API v2 https://clinicaltrials.gov/data-api/api

Analysis of 100,000 active/recruiting/completed trials on ClinicalTrials.gov (as of January 2025) shows cumulative enrollment of 12.2 million participants: Phase 1 (722k), Phase 2 (2.2M), Phase 3 (6.5M), Phase 4 (2.7M). Median participants per trial: Phase 1 (33), Phase 2 (60), Phase 3 (237), Phase 4 (90). Additional sources: https://clinicaltrials.gov/data-api/api

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16.

ACS CAN. Clinical trial patient participation rate. ACS CAN: Barriers to Clinical Trial Enrollment https://www.fightcancer.org/policy-resources/barriers-patient-enrollment-therapeutic-clinical-trials-cancer

Only 3-5% of adult cancer patients in US receive treatment within clinical trials About 5% of American adults have ever participated in any clinical trial Oncology: 2-3% of all oncology patients participate Contrast: 50-60% enrollment for pediatric cancer trials (<15 years old) Note:  20% of cancer trials fail due to insufficient enrollment; 11% of research sites enroll zero patients Additional sources: https://www.fightcancer.org/policy-resources/barriers-patient-enrollment-therapeutic-clinical-trials-cancer | https://hints.cancer.gov/docs/Briefs/HINTS_Brief_48.pdf

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17.

ScienceDaily. Global prevalence of chronic disease. ScienceDaily: GBD 2015 Study https://www.sciencedaily.com/releases/2015/06/150608081753.htm (2015)

2.3 billion individuals had more than five ailments (2013) Chronic conditions caused 74% of all deaths worldwide (2019), up from 67% (2010) Approximately 1 in 3 adults suffer from multiple chronic conditions (MCCs) Risk factor exposures: 2B exposed to biomass fuel, 1B to air pollution, 1B smokers Projected economic cost: $47 trillion by 2030 Note: 2.3B with 5+ ailments is more accurate than "2B with chronic disease." One-third of all adults globally have multiple chronic conditions Additional sources: https://www.sciencedaily.com/releases/2015/06/150608081753.htm | https://pmc.ncbi.nlm.nih.gov/articles/PMC10830426/ | https://pmc.ncbi.nlm.nih.gov/articles/PMC6214883/

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18.

C&EN. Annual number of new drugs approved globally:  50. C&EN https://cen.acs.org/pharmaceuticals/50-new-drugs-received-FDA/103/i2 (2025)

50 new drugs approved annually Additional sources: https://cen.acs.org/pharmaceuticals/50-new-drugs-received-FDA/103/i2 | https://www.fda.gov/drugs/development-approval-process-drugs/novel-drug-approvals-fda

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19.

Williams, R. J., Tse, T., DiPiazza, K. & Zarin, D. A. Terminated trials in the ClinicalTrials.gov results database: Evaluation of availability of primary outcome data and reasons for termination. PLOS One 10, e0127242 (2015)

Approximately 12% of trials with results posted on the ClinicalTrials.gov results database (905/7,646) were terminated. Primary reasons: insufficient accrual (57% of non-data-driven terminations), business/strategic reasons, and efficacy/toxicity findings (21% data-driven terminations).

20.

IQVIA Report. Global trial capacity. IQVIA Report: Clinical Trial Subjects Number Drops Due to Decline in COVID-19 Enrollment https://gmdpacademy.org/news/iqvia-report-clinical-trial-subjects-number-drops-due-to-decline-in-covid-19-enrollment/

1.9M participants annually (2022, post-COVID normalization from 4M peak in 2021) Additional sources: https://gmdpacademy.org/news/iqvia-report-clinical-trial-subjects-number-drops-due-to-decline-in-covid-19-enrollment/

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21.

Research and Markets. Global clinical trials market 2024. Research and Markets https://www.globenewswire.com/news-release/2024/04/19/2866012/0/en/Global-Clinical-Trials-Market-Research-Report-2024-An-83-16-Billion-Market-by-2030-AI-Machine-Learning-and-Blockchain-will-Transform-the-Clinical-Trials-Landscape.html (2024)

Global clinical trials market valued at approximately $83 billion in 2024, with projections to reach $83-132 billion by 2030. Additional sources: https://www.globenewswire.com/news-release/2024/04/19/2866012/0/en/Global-Clinical-Trials-Market-Research-Report-2024-An-83-16-Billion-Market-by-2030-AI-Machine-Learning-and-Blockchain-will-Transform-the-Clinical-Trials-Landscape.html | https://www.precedenceresearch.com/clinical-trials-market

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22.

OpenSecrets. Lobbying spend (defense). OpenSecrets https://www.opensecrets.org/industries/lobbying?ind=D (2024).

23.

Rummel, R. J. Death by Government: Genocide and Mass Murder Since 1900. (Transaction Publishers, 1994).

Political scientist R.J. Rummel’s comprehensive accounting of democide (government murder of unarmed civilians) in the 20th century. His final revised estimate: 262 million people murdered by their own governments from 1900-1999, excluding battle deaths in wars. Range: 200-272+ million. Communist regimes account for the largest share (100-148+ million). Updated figures at hawaii.edu/powerkills.

24.

GiveWell. Cost per DALY for deworming programs. https://www.givewell.org/international/technical/programs/deworming/cost-effectiveness

Schistosomiasis treatment: $28.19-$70.48 per DALY (using arithmetic means with varying disability weights) Soil-transmitted helminths (STH) treatment: $82.54 per DALY (midpoint estimate) Note: GiveWell explicitly states this 2011 analysis is "out of date" and their current methodology focuses on long-term income effects rather than short-term health DALYs Additional sources: https://www.givewell.org/international/technical/programs/deworming/cost-effectiveness

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25.

Calculated from IHME Global Burden of Disease (2.55B DALYs) and global GDP per capita valuation. $109 trillion annual global disease burden.

The global economic burden of disease, including direct healthcare costs ($8.2 trillion) and lost productivity ($100.9 trillion from 2.55 billion DALYs × $39,570 per DALY), totals approximately $109.1 trillion annually.

26.

U.S. Department of Transportation. Departmental guidance on valuation of a statistical life in economic analysis. (2024).

27.

Think by Numbers. Pre-1962 drug development costs and timeline (think by numbers). Think by Numbers: How Many Lives Does FDA Save? https://thinkbynumbers.org/health/how-many-net-lives-does-the-fda-save/ (1962)

Historical estimates (1970-1985): USD $226M fully capitalized (2011 prices) 1980s drugs:  $65M after-tax R&D (1990 dollars),  $194M compounded to approval (1990 dollars) Modern comparison: $2-3B costs, 7-12 years (dramatic increase from pre-1962) Context: 1962 regulatory clampdown reduced new treatment production by 70%, dramatically increasing development timelines and costs Note: Secondary source; less reliable than Congressional testimony Additional sources: https://thinkbynumbers.org/health/how-many-net-lives-does-the-fda-save/ | https://en.wikipedia.org/wiki/Cost_of_drug_development | https://www.statnews.com/2018/10/01/changing-1962-law-slash-drug-prices/

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28.

Biotechnology Innovation Organization (BIO). BIO clinical development success rates 2011-2020. Biotechnology Innovation Organization (BIO) https://go.bio.org/rs/490-EHZ-999/images/ClinicalDevelopmentSuccessRates2011_2020.pdf (2021)

Phase I duration: 2.3 years average Total time to market (Phase I-III + approval): 10.5 years average Phase transition success rates: Phase I→II: 63.2%, Phase II→III: 30.7%, Phase III→Approval: 58.1% Overall probability of approval from Phase I: 12% Note: Largest publicly available study of clinical trial success rates. Efficacy lag = 10.5 - 2.3 = 8.2 years post-safety verification. Additional sources: https://go.bio.org/rs/490-EHZ-999/images/ClinicalDevelopmentSuccessRates2011_2020.pdf

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29.

Nature Medicine. Drug repurposing rate ( 30%). Nature Medicine https://www.nature.com/articles/s41591-024-03233-x (2024)

Approximately 30% of drugs gain at least one new indication after initial approval. Additional sources: https://www.nature.com/articles/s41591-024-03233-x

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30.

EPI. Education investment economic multiplier (2.1). EPI: Public Investments Outside Core Infrastructure https://www.epi.org/publication/bp348-public-investments-outside-core-infrastructure/

Early childhood education: Benefits 12X outlays by 2050; $8.70 per dollar over lifetime Educational facilities: $1 spent → $1.50 economic returns Energy efficiency comparison: 2-to-1 benefit-to-cost ratio (McKinsey) Private return to schooling:  9% per additional year (World Bank meta-analysis) Note: 2.1 multiplier aligns with benefit-to-cost ratios for educational infrastructure/energy efficiency. Early childhood education shows much higher returns (12X by 2050) Additional sources: https://www.epi.org/publication/bp348-public-investments-outside-core-infrastructure/ | https://documents1.worldbank.org/curated/en/442521523465644318/pdf/WPS8402.pdf | https://freopp.org/whitepapers/establishing-a-practical-return-on-investment-framework-for-education-and-skills-development-to-expand-economic-opportunity/

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31.

PMC. Healthcare investment economic multiplier (1.8). PMC: California Universal Health Care https://pmc.ncbi.nlm.nih.gov/articles/PMC5954824/ (2022)

Healthcare fiscal multiplier: 4.3 (95% CI: 2.5-6.1) during pre-recession period (1995-2007) Overall government spending multiplier: 1.61 (95% CI: 1.37-1.86) Why healthcare has high multipliers: No effect on trade deficits (spending stays domestic); improves productivity & competitiveness; enhances long-run potential output Gender-sensitive fiscal spending (health & care economy) produces substantial positive growth impacts Note: "1.8" appears to be conservative estimate; research shows healthcare multipliers of 4.3 Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC5954824/ | https://cepr.org/voxeu/columns/government-investment-and-fiscal-stimulus | https://ncbi.nlm.nih.gov/pmc/articles/PMC3849102/ | https://set.odi.org/wp-content/uploads/2022/01/Fiscal-multipliers-review.pdf

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32.

World Bank. Infrastructure investment economic multiplier (1.6). World Bank: Infrastructure Investment as Stimulus https://blogs.worldbank.org/en/ppps/effectiveness-infrastructure-investment-fiscal-stimulus-what-weve-learned (2022)

Infrastructure fiscal multiplier:  1.6 during contractionary phase of economic cycle Average across all economic states:  1.5 (meaning $1 of public investment → $1.50 of economic activity) Time horizon: 0.8 within 1 year,  1.5 within 2-5 years Range of estimates: 1.5-2.0 (following 2008 financial crisis & American Recovery Act) Italian public construction: 1.5-1.9 multiplier US ARRA: 0.4-2.2 range (differential impacts by program type) Economic Policy Institute: Uses 1.6 for infrastructure spending (middle range of estimates) Note: Public investment less likely to crowd out private activity during recessions; particularly effective when monetary policy loose with near-zero rates Additional sources: https://blogs.worldbank.org/en/ppps/effectiveness-infrastructure-investment-fiscal-stimulus-what-weve-learned | https://www.gihub.org/infrastructure-monitor/insights/fiscal-multiplier-effect-of-infrastructure-investment/ | https://cepr.org/voxeu/columns/government-investment-and-fiscal-stimulus | https://www.richmondfed.org/publications/research/economic_brief/2022/eb_22-04

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33.

Mercatus. Military spending economic multiplier (0.6). Mercatus: Defense Spending and Economy https://www.mercatus.org/research/research-papers/defense-spending-and-economy

Ramey (2011):  0.6 short-run multiplier Barro (1981): 0.6 multiplier for WWII spending (war spending crowded out  40¢ private economic activity per federal dollar) Barro & Redlick (2011): 0.4 within current year, 0.6 over two years; increased govt spending reduces private-sector GDP portions General finding: $1 increase in deficit-financed federal military spending = less than $1 increase in GDP Variation by context: Central/Eastern European NATO: 0.6 on impact, 1.5-1.6 in years 2-3, gradual fall to zero Ramey & Zubairy (2018): Cumulative 1% GDP increase in military expenditure raises GDP by  0.7% Additional sources: https://www.mercatus.org/research/research-papers/defense-spending-and-economy | https://cepr.org/voxeu/columns/world-war-ii-america-spending-deficits-multipliers-and-sacrifice | https://www.rand.org/content/dam/rand/pubs/research_reports/RRA700/RRA739-2/RAND_RRA739-2.pdf

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34.

FDA. FDA-approved prescription drug products (20,000+). FDA https://www.fda.gov/media/143704/download

There are over 20,000 prescription drug products approved for marketing. Additional sources: https://www.fda.gov/media/143704/download

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35.

FDA. FDA GRAS list count ( 570-700). FDA https://www.fda.gov/food/generally-recognized-safe-gras/gras-notice-inventory

The FDA GRAS (Generally Recognized as Safe) list contains approximately 570–700 substances. Additional sources: https://www.fda.gov/food/generally-recognized-safe-gras/gras-notice-inventory

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36.

ACLED. Active combat deaths annually. ACLED: Global Conflict Surged 2024 https://acleddata.com/2024/12/12/data-shows-global-conflict-surged-in-2024-the-washington-post/ (2024)

2024: 233,597 deaths (30% increase from 179,099 in 2023) Deadliest conflicts: Ukraine (67,000), Palestine (35,000) Nearly 200,000 acts of violence (25% higher than 2023, double from 5 years ago) One in six people globally live in conflict-affected areas Additional sources: https://acleddata.com/2024/12/12/data-shows-global-conflict-surged-in-2024-the-washington-post/ | https://acleddata.com/media-citation/data-shows-global-conflict-surged-2024-washington-post | https://acleddata.com/conflict-index/index-january-2024/

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37.

UCDP. State violence deaths annually. UCDP: Uppsala Conflict Data Program https://ucdp.uu.se/

Uppsala Conflict Data Program (UCDP): Tracks one-sided violence (organized actors attacking unarmed civilians) UCDP definition: Conflicts causing at least 25 battle-related deaths in calendar year 2023 total organized violence: 154,000 deaths; Non-state conflicts: 20,900 deaths UCDP collects data on state-based conflicts, non-state conflicts, and one-sided violence Specific "2,700 annually" figure for state violence not found in recent UCDP data; actual figures vary annually Additional sources: https://ucdp.uu.se/ | https://en.wikipedia.org/wiki/Uppsala_Conflict_Data_Program | https://ourworldindata.org/grapher/deaths-in-armed-conflicts-by-region

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38.

Our World in Data. Terror attack deaths (8,300 annually). Our World in Data: Terrorism https://ourworldindata.org/terrorism (2024)

2023: 8,352 deaths (22% increase from 2022, highest since 2017) 2023: 3,350 terrorist incidents (22% decrease), but 56% increase in avg deaths per attack Global Terrorism Database (GTD): 200,000+ terrorist attacks recorded (2021 version) Maintained by: National Consortium for Study of Terrorism & Responses to Terrorism (START), U. of Maryland Geographic shift: Epicenter moved from Middle East to Central Sahel (sub-Saharan Africa) - now >50% of all deaths Additional sources: https://ourworldindata.org/terrorism | https://reliefweb.int/report/world/global-terrorism-index-2024 | https://www.start.umd.edu/gtd/ | https://ourworldindata.org/grapher/fatalities-from-terrorism

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39.

Institute for Health Metrics and Evaluation (IHME). IHME global burden of disease 2021 (2.88B DALYs, 1.13B YLD). Institute for Health Metrics and Evaluation (IHME) https://vizhub.healthdata.org/gbd-results/ (2024)

In 2021, global DALYs totaled approximately 2.88 billion, comprising 1.75 billion Years of Life Lost (YLL) and 1.13 billion Years Lived with Disability (YLD). This represents a 13% increase from 2019 (2.55B DALYs), largely attributable to COVID-19 deaths and aging populations. YLD accounts for approximately 39% of total DALYs, reflecting the substantial burden of non-fatal chronic conditions. Additional sources: https://vizhub.healthdata.org/gbd-results/ | https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)00757-8/fulltext | https://www.healthdata.org/research-analysis/about-gbd

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40.

Costs of War Project, Brown University Watson Institute. Environmental cost of war ($100B annually). Brown Watson Costs of War: Environmental Cost https://watson.brown.edu/costsofwar/costs/social/environment

War on Terror emissions: 1.2B metric tons GHG (equivalent to 257M cars/year) Military: 5.5% of global GHG emissions (2X aviation + shipping combined) US DoD: World’s single largest institutional oil consumer, 47th largest emitter if nation Cleanup costs: $500B+ for military contaminated sites Gaza war environmental damage: $56.4B; landmine clearance: $34.6B expected Climate finance gap: Rich nations spend 30X more on military than climate finance Note: Military activities cause massive environmental damage through GHG emissions, toxic contamination, and long-term cleanup costs far exceeding current climate finance commitments Additional sources: https://watson.brown.edu/costsofwar/costs/social/environment | https://earth.org/environmental-costs-of-wars/ | https://transformdefence.org/transformdefence/stats/

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41.

ScienceDaily. Medical research lives saved annually (4.2 million). ScienceDaily: Physical Activity Prevents 4M Deaths https://www.sciencedaily.com/releases/2020/06/200617194510.htm (2020)

Physical activity: 3.9M early deaths averted annually worldwide (15% lower premature deaths than without) COVID vaccines (2020-2024): 2.533M deaths averted, 14.8M life-years preserved; first year alone: 14.4M deaths prevented Cardiovascular prevention: 3 interventions could delay 94.3M deaths over 25 years (antihypertensives alone: 39.4M) Pandemic research response: Millions of deaths averted through rapid vaccine/drug development Additional sources: https://www.sciencedaily.com/releases/2020/06/200617194510.htm | https://pmc.ncbi.nlm.nih.gov/articles/PMC9537923/ | https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.038160 | https://pmc.ncbi.nlm.nih.gov/articles/PMC9464102/

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42.

SIPRI. 36:1 disparity ratio of spending on weapons over cures. SIPRI: Military Spending https://www.sipri.org/commentary/blog/2016/opportunity-cost-world-military-spending (2016)

Global military spending: $2.7 trillion (2024, SIPRI) Global government medical research:  $68 billion (2024) Actual ratio: 39.7:1 in favor of weapons over medical research Military R&D alone:  $85B (2004 data, 10% of global R&D) Military spending increases crowd out health: 1% ↑ military = 0.62% ↓ health spending Note: Ratio actually worse than 36:1. Each 1% increase in military spending reduces health spending by 0.62%, with effect more intense in poorer countries (0.962% reduction) Additional sources: https://www.sipri.org/commentary/blog/2016/opportunity-cost-world-military-spending | https://pmc.ncbi.nlm.nih.gov/articles/PMC9174441/ | https://www.congress.gov/crs-product/R45403

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43.

Think by Numbers. Lost human capital due to war ($270B annually). Think by Numbers https://thinkbynumbers.org/military/war/the-economic-case-for-peace-a-comprehensive-financial-analysis/ (2021)

Lost human capital from war: $300B annually (economic impact of losing skilled/productive individuals to conflict) Broader conflict/violence cost: $14T/year globally 1.4M violent deaths/year; conflict holds back economic development, causes instability, widens inequality, erodes human capital 2002: 48.4M DALYs lost from 1.6M violence deaths = $151B economic value (2000 USD) Economic toll includes: commodity prices, inflation, supply chain disruption, declining output, lost human capital Additional sources: https://thinkbynumbers.org/military/war/the-economic-case-for-peace-a-comprehensive-financial-analysis/ | https://www.weforum.org/stories/2021/02/war-violence-costs-each-human-5-a-day/ | https://pubmed.ncbi.nlm.nih.gov/19115548/

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44.

PubMed. Psychological impact of war cost ($100B annually). PubMed: Economic Burden of PTSD https://pubmed.ncbi.nlm.nih.gov/35485933/

PTSD economic burden (2018 U.S.): $232.2B total ($189.5B civilian, $42.7B military) Civilian costs driven by: Direct healthcare ($66B), unemployment ($42.7B) Military costs driven by: Disability ($17.8B), direct healthcare ($10.1B) Exceeds costs of other mental health conditions (anxiety, depression) War-exposed populations: 2-3X higher rates of anxiety, depression, PTSD; women and children most vulnerable Note: Actual burden $232B, significantly higher than "$100B" claimed Additional sources: https://pubmed.ncbi.nlm.nih.gov/35485933/ | https://news.va.gov/103611/study-national-economic-burden-of-ptsd-staggering/ | https://pmc.ncbi.nlm.nih.gov/articles/PMC9957523/

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45.

CGDev. UNHCR average refugee support cost. CGDev https://www.cgdev.org/blog/costs-hosting-refugees-oecd-countries-and-why-uk-outlier (2024)

The average cost of supporting a refugee is $1,384 per year. This represents total host country costs (housing, healthcare, education, security). OECD countries average $6,100 per refugee (mean 2022-2023), with developing countries spending $700-1,000. Global weighted average of  $1,384 is reasonable given that 75-85% of refugees are in low/middle-income countries. Additional sources: https://www.cgdev.org/blog/costs-hosting-refugees-oecd-countries-and-why-uk-outlier | https://www.unhcr.org/sites/default/files/2024-11/UNHCR-WB-global-cost-of-refugee-inclusion-in-host-country-health-systems.pdf

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46.

World Bank. World bank trade disruption cost from conflict. World Bank https://www.worldbank.org/en/topic/trade/publication/trading-away-from-conflict

Estimated $616B annual cost from conflict-related trade disruption. World Bank research shows civil war costs an average developing country 30 years of GDP growth, with 20 years needed for trade to return to pre-war levels. Trade disputes analysis shows tariff escalation could reduce global exports by up to $674 billion. Additional sources: https://www.worldbank.org/en/topic/trade/publication/trading-away-from-conflict | https://www.nber.org/papers/w11565 | http://blogs.worldbank.org/en/trade/impacts-global-trade-and-income-current-trade-disputes

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47.

VA. Veteran healthcare cost projections. VA https://department.va.gov/wp-content/uploads/2025/06/2026-Budget-in-Brief.pdf (2026)

VA budget: $441.3B requested for FY 2026 (10% increase). Disability compensation: $165.6B in FY 2024 for 6.7M veterans. PACT Act projected to increase spending by $300B between 2022-2031. Costs under Toxic Exposures Fund: $20B (2024), $30.4B (2025), $52.6B (2026). Additional sources: https://department.va.gov/wp-content/uploads/2025/06/2026-Budget-in-Brief.pdf | https://www.cbo.gov/publication/45615 | https://www.legion.org/information-center/news/veterans-healthcare/2025/june/va-budget-tops-400-billion-for-2025-from-higher-spending-on-mandated-benefits-medical-care

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48.

IQVIA Institute for Human Data Science. The global use of medicines 2024: Outlook to 2028. IQVIA Institute Report https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-global-use-of-medicines-2024-outlook-to-2028 (2024)

Global days of therapy reached 1.8 trillion in 2019 (234 defined daily doses per person). Diabetes, respiratory, CVD, and cancer account for 71 percent of medicine use. Projected to reach 3.8 trillion DDDs by 2028.

49.

Sinn, M. P. Private industry clinical trial spending estimate. (2025)

Estimated private pharmaceutical and biotech clinical trial spending is approximately $75-90 billion annually, representing roughly 90% of global clinical trial spending.

50.

Cybersecurity Ventures. Cybercrime economy projected to reach $10.5 trillion. Cybersecurity Ventures: $10.5T Cybercrime https://cybersecurityventures.com/hackerpocalypse-cybercrime-report-2016/ (2016)

Global cybercrime costs: $3T (2015) → $6T (2021) → $10.5T (2025 projected) 15% annual growth rate If measured as country, would be 3rd largest economy after US and China Greatest transfer of economic wealth in history Note: More profitable than global trade of all major illegal drugs combined. Includes data theft, productivity loss, IP theft, fraud Additional sources: <https://cybersecurityventures.com/hackerpocalypse-cybercrime-report-2016/> | https://www.boisestate.edu/cybersecurity/2022/06/16/cybercrime-to-cost-the-world-10-5-trillion-annually-by-2025/

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51.

Sinn, M. P. The Political Dysfunction Tax. https://manual.warondisease.org/knowledge/appendix/political-dysfunction-tax.html (2025) doi:10.5281/zenodo.18603840

Quantifying the gap between current global governance and theoretical maximum welfare, estimating a 31-53% efficiency score and $97 trillion in annual opportunity costs.

52.

Bolt, J. & Zanden, J. L. van. Maddison project database 2020. (2020)

Historical GDP per capita estimates from year 1 to present. Global GDP per capita in 1900: approximately 1,260 in 1990 international dollars (roughly 3,150 in 2024 USD after PPP and inflation adjustment). Standard reference for long-run comparative economic history.

53.

Applied Clinical Trials. Global government spending on interventional clinical trials:  $3-6 billion/year. Applied Clinical Trials https://www.appliedclinicaltrialsonline.com/view/sizing-clinical-research-market

Estimated range based on NIH ( $0.8-5.6B), NIHR ($1.6B total budget), and EU funding ( $1.3B/year). Roughly 5-10% of global market. Additional sources: https://www.appliedclinicaltrialsonline.com/view/sizing-clinical-research-market | https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30357-0/fulltext

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54.

UBS. Credit suisse global wealth report 2023. Credit Suisse/UBS https://www.ubs.com/global/en/family-office-uhnw/reports/global-wealth-report-2023.html (2023)

Total global household wealth: USD 454.4 trillion (2022) Wealth declined by USD 11.3 trillion (-2.4%) in 2022, first decline since 2008 Wealth per adult: USD 84,718 Additional sources: https://www.ubs.com/global/en/family-office-uhnw/reports/global-wealth-report-2023.html

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55.

Component country budgets. Global government medical research spending ($67.5B, 2023–2024). See component country budgets: NIH Budget https://www.nih.gov/about-nih/what-we-do/budget.

56.

United Nations Department of Economic and Social Affairs, Population Division. World population prospects 2024: Summary of results. (2024)

The 2024 Revision of the World Population Prospects provides population estimates and projections for 237 countries or areas. Global median age approximately 30.5 years in 2024, reflecting population-weighted average across all regions.

57.

Stockholm International Peace Research Institute. Trends in world military expenditure, 2024. (2025).

58.

SIPRI. Global military spending ($2.72T, 2024). SIPRI https://www.sipri.org/publications/2025/sipri-fact-sheets/trends-world-military-expenditure-2024 (2025).

59.

Estimated from major foundation budgets and activities. Nonprofit clinical trial funding estimate.

Nonprofit foundations spend an estimated $2-5 billion annually on clinical trials globally, representing approximately 2-5% of total clinical trial spending.

60.

ICAN. Global nuclear weapon maintenance cost: $100 billion/year. ICAN: Global Spending $100B 2024 https://www.icanw.org/global_spending_on_nuclear_weapons_topped_100_billion_in_2024 (2024)

2024: >$100 billion ($190,151/minute) - 11% increase ($9.9B) from 2023 Nine nuclear-armed states: China, France, India, Israel, N. Korea, Pakistan, Russia, UK, US US: $56.8B (more than all other 8 states combined); China: $12.5B; UK: $10B (+26% YoY, biggest increase) Historical trend: $72.9B (2019) → $82.4B (2021) → >$100B (2024) Private sector contracts: $463B ongoing; $42.5B earned from contracts in 2024 alone Note: $100B/year figure accurate for 2024. Rapid growth from $73B (2019). US spends more than rest of world combined on nuclear weapons Additional sources: https://www.icanw.org/global_spending_on_nuclear_weapons_topped_100_billion_in_2024 | https://www.icanw.org/the_cost_of_nuclear_weapons

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61.

Industry reports: IQVIA. Global pharmaceutical r&d spending.

Total global pharmaceutical R&D spending is approximately $300 billion annually. Clinical trials represent 15-20% of this total ($45-60B), with the remainder going to drug discovery, preclinical research, regulatory affairs, and manufacturing development.

62.

UN. Global population reaches 8 billion. UN: World Population 8 Billion Nov 15 2022 https://www.un.org/en/desa/world-population-reach-8-billion-15-november-2022 (2022)

Milestone: November 15, 2022 (UN World Population Prospects 2022) Day of Eight Billion" designated by UN Added 1 billion people in just 11 years (2011-2022) Growth rate: Slowest since 1950; fell under 1% in 2020 Future: 15 years to reach 9B (2037); projected peak 10.4B in 2080s Projections: 8.5B (2030), 9.7B (2050), 10.4B (2080-2100 plateau) Note: Milestone reached Nov 2022. Population growth slowing; will take longer to add next billion (15 years vs 11 years) Additional sources: https://www.un.org/en/desa/world-population-reach-8-billion-15-november-2022 | https://www.un.org/en/dayof8billion | https://en.wikipedia.org/wiki/Day_of_Eight_Billion

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63.

Harvard Kennedy School. 3.5% participation tipping point. Harvard Kennedy School https://www.hks.harvard.edu/centers/carr/publications/35-rule-how-small-minority-can-change-world (2020)

The research found that nonviolent campaigns were twice as likely to succeed as violent ones, and once 3.5% of the population were involved, they were always successful. Chenoweth and Maria Stephan studied the success rates of civil resistance efforts from 1900 to 2006, finding that nonviolent movements attracted, on average, four times as many participants as violent movements and were more likely to succeed. Key finding: Every campaign that mobilized at least 3.5% of the population in sustained protest was successful (in their 1900-2006 dataset) Note: The 3.5% figure is a descriptive statistic from historical analysis, not a guaranteed threshold. One exception (Bahrain 2011-2014 with 6%+ participation) has been identified. The rule applies to regime change, not policy change in democracies. Additional sources: https://www.hks.harvard.edu/centers/carr/publications/35-rule-how-small-minority-can-change-world | https://www.hks.harvard.edu/sites/default/files/2024-05/Erica%20Chenoweth_2020-005.pdf | https://www.bbc.com/future/article/20190513-it-only-takes-35-of-people-to-change-the-world | https://en.wikipedia.org/wiki/3.5%25_rule

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64.

International IDEA. International IDEA voter turnout database world export. (2026)

Best current register-based estimate of global registered voters. Sum of the latest available country-level Registration counts in International IDEA’s world export on 2026-04-22 = 4,128,142,495 registered voters across 199 countries and political entities. Methodology notes that Registration is the number of names on the voters’ register as reported by electoral management bodies, and comparability is imperfect because voter rolls and registration systems differ across countries. Additional sources: https://www.idea.int/data-tools/data/voter-turnout-database | https://www.idea.int/data-tools/export?type=region_only&themeId=293&world=all&loc=home

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65.

World Bank. Gross savings (% of GDP). (2024).

66.

Federation of American Scientists. World nuclear forces. Federation of American Scientists https://fas.org/issues/nuclear-weapons/status-world-nuclear-forces/ (2024)

As of early 2025, we estimate that the world’s nine nuclear-armed states possess a combined total of approximately 12,241 nuclear warheads. Additional sources: https://fas.org/issues/nuclear-weapons/status-world-nuclear-forces/

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67.

NHGRI. Human genome project and CRISPR discovery. NHGRI https://www.genome.gov/11006929/2003-release-international-consortium-completes-hgp (2003)

Your DNA is 3 billion base pairs Read the entire code (Human Genome Project, completed 2003) Learned to edit it (CRISPR, discovered 2012) Additional sources: https://www.genome.gov/11006929/2003-release-international-consortium-completes-hgp | https://www.nobelprize.org/prizes/chemistry/2020/press-release/

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68.

PMC. Only  12% of human interactome targeted. PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC10749231/ (2023)

Mapping 350,000+ clinical trials showed that only  12% of the human interactome has ever been targeted by drugs. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC10749231/

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69.

WHO. ICD-10 code count ( 14,000). WHO https://icd.who.int/browse10/2019/en (2019)

The ICD-10 classification contains approximately 14,000 codes for diseases, signs and symptoms. Additional sources: https://icd.who.int/browse10/2019/en

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70.

Wikipedia. Longevity escape velocity (LEV) - maximum human life extension potential. Wikipedia: Longevity Escape Velocity https://en.wikipedia.org/wiki/Longevity_escape_velocity

Longevity escape velocity: Hypothetical point where medical advances extend life expectancy faster than time passes Term coined by Aubrey de Grey (biogerontologist) in 2004 paper; concept from David Gobel (Methuselah Foundation) Current progress: Science adds  3 months to lifespan per year; LEV requires adding >1 year per year Sinclair (Harvard): "There is no biological upper limit to age" - first person to live to 150 may already be born De Grey: 50% chance of reaching LEV by mid-to-late 2030s; SENS approach = damage repair rather than slowing damage Kurzweil (2024): LEV by 2029-2035, AI will simulate biological processes to accelerate solutions George Church: LEV "in a decade or two" via age-reversal clinical trials Natural lifespan cap:  120-150 years (Jeanne Calment record: 122); engineering approach could bypass via damage repair Key mechanisms: Epigenetic reprogramming, senolytic drugs, stem cell therapy, gene therapy, AI-driven drug discovery Current record: Jeanne Calment (122 years, 164 days) - record unbroken since 1997 Note: LEV is theoretical but increasingly plausible given demonstrated age reversal in mice (109% lifespan extension) and human cells (30-year epigenetic age reversal) Additional sources: https://en.wikipedia.org/wiki/Longevity_escape_velocity | https://pmc.ncbi.nlm.nih.gov/articles/PMC423155/ | https://www.popularmechanics.com/science/a36712084/can-science-cure-death-longevity/ | https://www.diamandis.com/blog/longevity-escape-velocity

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71.

OpenSecrets. Lobbyist statistics for washington d.c. OpenSecrets: Lobbying in US https://en.wikipedia.org/wiki/Lobbying_in_the_United_States

Registered lobbyists: Over 12,000 (some estimates); 12,281 registered (2013) Former government employees as lobbyists: 2,200+ former federal employees (1998-2004), including 273 former White House staffers,  250 former Congress members & agency heads Congressional revolving door: 43% (86 of 198) lawmakers who left 1998-2004 became lobbyists; currently 59% leaving to private sector work for lobbying/consulting firms/trade groups Executive branch: 8% were registered lobbyists at some point before/after government service Additional sources: https://en.wikipedia.org/wiki/Lobbying_in_the_United_States | https://www.opensecrets.org/revolving-door | https://www.citizen.org/article/revolving-congress/ | https://www.propublica.org/article/we-found-a-staggering-281-lobbyists-whove-worked-in-the-trump-administration

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72.

MDPI Vaccines. Measles vaccination ROI. MDPI Vaccines https://www.mdpi.com/2076-393X/12/11/1210 (2024)

Single measles vaccination: 167:1 benefit-cost ratio. MMR (measles-mumps-rubella) vaccination: 14:1 ROI. Historical US elimination efforts (1966-1974): benefit-cost ratio of 10.3:1 with net benefits exceeding USD 1.1 billion (1972 dollars, or USD 8.0 billion in 2023 dollars). 2-dose MMR programs show direct benefit/cost ratio of 14.2 with net savings of $5.3 billion, and 26.0 from societal perspectives with net savings of $11.6 billion. Additional sources: https://www.mdpi.com/2076-393X/12/11/1210 | https://www.tandfonline.com/doi/full/10.1080/14760584.2024.2367451

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73.

Gosse, M. E. Assessing cost-effectiveness in healthcare: History of the $50,000 per QALY threshold. Sustainability Impact Metrics https://ecocostsvalue.com/EVR/img/references%20others/Gosse%202008%20QALY%20threshold%20financial.pdf (2008).

74.

World Health Organization. Mental health global burden. World Health Organization https://www.who.int/news/item/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-in-four-people (2022)

One in four people in the world will be affected by mental or neurological disorders at some point in their lives, representing [approximately] 30% of the global burden of disease. Additional sources: https://www.who.int/news/item/28-09-2001-the-world-health-report-2001-mental-disorders-affect-one-in-four-people

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75.

Stockholm International Peace Research Institute. Trends in world military expenditure, 2023. (2024).

76.

Calculated from Orphanet Journal of Rare Diseases (2024). Diseases getting first effective treatment each year. Calculated from Orphanet Journal of Rare Diseases (2024) https://ojrd.biomedcentral.com/articles/10.1186/s13023-024-03398-1 (2024)

Under the current system, approximately 10-15 diseases per year receive their FIRST effective treatment. Calculation: 5% of 7,000 rare diseases ( 350) have FDA-approved treatment, accumulated over 40 years of the Orphan Drug Act =  9 rare diseases/year. Adding  5-10 non-rare diseases that get first treatments yields  10-20 total. FDA approves  50 drugs/year, but many are for diseases that already have treatments (me-too drugs, second-line therapies). Only  15 represent truly FIRST treatments for previously untreatable conditions.

77.

NIH. NIH budget (FY 2025). NIH https://www.nih.gov/about-nih/organization/budget (2024)

The budget total of $47.7 billion also includes $1.412 billion derived from PHS Evaluation financing... Additional sources: https://www.nih.gov/about-nih/organization/budget | https://officeofbudget.od.nih.gov/

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78.

Bentley et al. NIH spending on clinical trials:  3.3%. Bentley et al. https://pmc.ncbi.nlm.nih.gov/articles/PMC10349341/ (2023)

NIH spent $8.1 billion on clinical trials for approved drugs (2010-2019), representing 3.3% of relevant NIH spending. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC10349341/ | https://catalyst.harvard.edu/news/article/nih-spent-8-1b-for-phased-clinical-trials-of-drugs-approved-2010-19-10-of-reported-industry-spending/

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79.

PMC. Standard medical research ROI ($20k-$100k/QALY). PMC: Cost-effectiveness Thresholds Used by Study Authors https://pmc.ncbi.nlm.nih.gov/articles/PMC10114019/ (1990)

Typical cost-effectiveness thresholds for medical interventions in rich countries range from $50,000 to $150,000 per QALY. The Institute for Clinical and Economic Review (ICER) uses a $100,000-$150,000/QALY threshold for value-based pricing. Between 1990-2021, authors increasingly cited $100,000 (47% by 2020-21) or $150,000 (24% by 2020-21) per QALY as benchmarks for cost-effectiveness. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC10114019/ | https://icer.org/our-approach/methods-process/cost-effectiveness-the-qaly-and-the-evlyg/

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80.

Xia et al., Nature Food. Nuclear winter famine. Xia et al. https://www.nature.com/articles/s43016-022-00573-0 (2022)

We estimate that a nuclear war between the United States and Russia would produce 150 Tg of soot and lead to  5 billion people dying at the end of year 2. Additional sources: https://www.nature.com/articles/s43016-022-00573-0

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81.

Manhattan Institute. RECOVERY trial 82× cost reduction. Manhattan Institute: Slow Costly Trials https://manhattan.institute/article/slow-costly-clinical-trials-drag-down-biomedical-breakthroughs

RECOVERY trial:  $500 per patient ($20M for 48,000 patients = $417/patient) Typical clinical trial:  $41,000 median per-patient cost Cost reduction:  80-82× cheaper ($41,000 ÷ $500 ≈ 82×) Efficiency: $50 per patient per answer (10 therapeutics tested, 4 effective) Dexamethasone estimated to save >630,000 lives Additional sources: https://manhattan.institute/article/slow-costly-clinical-trials-drag-down-biomedical-breakthroughs | https://pmc.ncbi.nlm.nih.gov/articles/PMC9293394/

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82.

Trials. Patient willingness to participate in clinical trials. Trials: Patients’ Willingness Survey https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-1105-3

Recent surveys: 49-51% willingness (2020-2022) - dramatic drop from 85% (2019) during COVID-19 pandemic Cancer patients when approached: 88% consented to trials (Royal Marsden Hospital) Study type variation: 44.8% willing for drug trial, 76.2% for diagnostic study Top motivation: "Learning more about my health/medical condition" (67.4%) Top barrier: "Worry about experiencing side effects" (52.6%) Additional sources: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-1105-3 | https://www.appliedclinicaltrialsonline.com/view/industry-forced-to-rethink-patient-participation-in-trials | https://pmc.ncbi.nlm.nih.gov/articles/PMC7183682/

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83.

The Commune. Pentagon audit failures ($2.46T unaccounted). The Commune https://thecommunemag.com/the-pentagon-misplaced-2-46-trillion-an-in-depth-look-at-the-financial-audit-failures (2024)

In the most recent audit, the Department of Defense (DoD) could not account for approximately 60% of its \(4.1 trillion in assets, amounting to\)2.46 trillion unaccounted for. Alternative title: Pentagon unsupported accounting adjustments (\(6.5T, single year, US Army) In 2015, the Department of Defense's Inspector General reported that the Army could not adequately support\)6.5 trillion in year-end adjustments, indicating severe accounting discrepancies. Additional sources: https://thecommunemag.com/the-pentagon-misplaced-2-46-trillion-an-in-depth-look-at-the-financial-audit-failures | https://accmag.com/audit-pentagon-cannot-account-for-6-5-trillion-dollars-is-taxpayer-money/

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84.

Tufts CSDD. Cost of drug development.

Various estimates suggest $1.0 - $2.5 billion to bring a new drug from discovery through FDA approval, spread across  10 years. Tufts Center for the Study of Drug Development often cited for $1.0 - $2.6 billion/drug. Industry reports (IQVIA, Deloitte) also highlight $2+ billion figures.

85.

Value in Health. Average lifetime revenue per successful drug. Value in Health: Sales Revenues for New Therapeutic Agents https://www.sciencedirect.com/science/article/pii/S1098301524027542

Study of 361 FDA-approved drugs from 1995-2014 (median follow-up 13.2 years): Mean lifetime revenue: $15.2 billion per drug Median lifetime revenue: $6.7 billion per drug Revenue after 5 years: $3.2 billion (mean) Revenue after 10 years: $9.5 billion (mean) Revenue after 15 years: $19.2 billion (mean) Distribution highly skewed: top 25 drugs (7%) accounted for 38% of total revenue ($2.1T of $5.5T) Additional sources: https://www.sciencedirect.com/science/article/pii/S1098301524027542

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86.

Lichtenberg, F. R. How many life-years have new drugs saved? A three-way fixed-effects analysis of 66 diseases in 27 countries, 2000-2013. International Health 11, 403–416 (2019)

Using 3-way fixed-effects methodology (disease-country-year) across 66 diseases in 22 countries, this study estimates that drugs launched after 1981 saved 148.7 million life-years in 2013 alone. The regression coefficients for drug launches 0-11 years prior (beta=-0.031, SE=0.008) and 12+ years prior (beta=-0.057, SE=0.013) on years of life lost are highly significant (p<0.0001). Confidence interval for life-years saved: 79.4M-239.8M (95 percent CI) based on propagated standard errors from Table 2.

87.

Deloitte. Pharmaceutical r&d return on investment (ROI). Deloitte: Measuring Pharmaceutical Innovation 2025 https://www.deloitte.com/ch/en/Industries/life-sciences-health-care/research/measuring-return-from-pharmaceutical-innovation.html (2025)

Deloitte’s annual study of top 20 pharma companies by R&D spend (2010-2024): 2024 ROI: 5.9% (second year of growth after decade of decline) 2023 ROI:  4.3% (estimated from trend) 2022 ROI: 1.2% (historic low since study began, 13-year low) 2021 ROI: 6.8% (record high, inflated by COVID-19 vaccines/treatments) Long-term trend: Declining for over a decade before 2023 recovery Average R&D cost per asset: $2.3B (2022), $2.23B (2024) These returns (1.2-5.9% range) fall far below typical corporate ROI targets (15-20%) Additional sources: https://www.deloitte.com/ch/en/Industries/life-sciences-health-care/research/measuring-return-from-pharmaceutical-innovation.html | https://www.prnewswire.com/news-releases/deloittes-13th-annual-pharmaceutical-innovation-report-pharma-rd-return-on-investment-falls-in-post-pandemic-market-301738807.html | https://hitconsultant.net/2023/02/16/pharma-rd-roi-falls-to-lowest-level-in-13-years/

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88.

Nature Reviews Drug Discovery. Drug trial success rate from phase i to approval. Nature Reviews Drug Discovery: Clinical Success Rates https://www.nature.com/articles/nrd.2016.136 (2016)

Overall Phase I to approval: 10-12.8% (conventional wisdom  10%, studies show 12.8%) Recent decline: Average LOA now 6.7% for Phase I (2014-2023 data) Leading pharma companies: 14.3% average LOA (range 8-23%) Varies by therapeutic area: Oncology 3.4%, CNS/cardiovascular lowest at Phase III Phase-specific success: Phase I 47-54%, Phase II 28-34%, Phase III 55-70% Note: 12% figure accurate for historical average. Recent data shows decline to 6.7%, with Phase II as primary attrition point (28% success) Additional sources: https://www.nature.com/articles/nrd.2016.136 | https://pmc.ncbi.nlm.nih.gov/articles/PMC6409418/ | https://academic.oup.com/biostatistics/article/20/2/273/4817524

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89.

SofproMed. Phase 3 cost per trial range. SofproMed https://www.sofpromed.com/how-much-does-a-clinical-trial-cost

Phase 3 clinical trials cost between $20 million and $282 million per trial, with significant variation by therapeutic area and trial complexity. Additional sources: https://www.sofpromed.com/how-much-does-a-clinical-trial-cost | https://www.cbo.gov/publication/57126

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90.

Ramsberg, J. & Platt, R. Pragmatic trial cost per patient (median $97). Learning Health Systems https://pmc.ncbi.nlm.nih.gov/articles/PMC6508852/ (2018)

Meta-analysis of 108 embedded pragmatic clinical trials (2006-2016). The median cost per patient was $97 (IQR $19–$478), based on 2015 dollars. 25% of trials cost <$19/patient; 10 trials exceeded $1,000/patient. U.S. studies median $187 vs non-U.S. median $27. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC6508852/

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91.

WHO. Polio vaccination ROI. WHO https://www.who.int/news-room/feature-stories/detail/sustaining-polio-investments-offers-a-high-return (2019)

For every dollar spent, the return on investment is nearly US$ 39." Total investment cost of US$ 7.5 billion generates projected economic and social benefits of US$ 289.2 billion from sustaining polio assets and integrating them into expanded immunization, surveillance and emergency response programmes across 8 priority countries (Afghanistan, Iraq, Libya, Pakistan, Somalia, Sudan, Syria, Yemen). Additional sources: https://www.who.int/news-room/feature-stories/detail/sustaining-polio-investments-offers-a-high-return

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92.

ICRC. International campaign to ban landmines (ICBL) - ottawa treaty (1997). ICRC https://www.icrc.org/en/doc/resources/documents/article/other/57jpjn.htm (1997)

ICBL: Founded 1992 by 6 NGOs (Handicap International, Human Rights Watch, Medico International, Mines Advisory Group, Physicians for Human Rights, Vietnam Veterans of America Foundation) Started with ONE staff member: Jody Williams as founding coordinator Grew to 1,000+ organizations in 60 countries by 1997 Ottawa Process: 14 months (October 1996 - December 1997) Convention signed by 122 states on December 3, 1997; entered into force March 1, 1999 Achievement: Nobel Peace Prize 1997 (shared by ICBL and Jody Williams) Government funding context: Canada established $100M CAD Canadian Landmine Fund over 10 years (1997); International donors provided $169M in 1997 for mine action (up from $100M in 1996) Additional sources: https://www.icrc.org/en/doc/resources/documents/article/other/57jpjn.htm | https://en.wikipedia.org/wiki/International_Campaign_to_Ban_Landmines | https://www.nobelprize.org/prizes/peace/1997/summary/ | https://un.org/press/en/1999/19990520.MINES.BRF.html | https://www.the-monitor.org/en-gb/reports/2003/landmine-monitor-2003/mine-action-funding.aspx

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93.

OpenSecrets. Revolving door: Former members of congress. (2024)

388 former members of Congress are registered as lobbyists. Nearly 5,400 former congressional staffers have left Capitol Hill to become federal lobbyists in the past 10 years. Additional sources: https://www.opensecrets.org/revolving-door

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94.

Kinch, M. S. & Griesenauer, R. H. Lost medicines: A longer view of the pharmaceutical industry with the potential to reinvigorate discovery. Drug Discovery Today 24, 875–880 (2019)

Research identified 1,600+ medicines available in 1962. The 1950s represented industry high-water mark with >30 new products in five of ten years; this rate would not be replicated until late 1990s. More than half (880) of these medicines were lost following implementation of Kefauver-Harris Amendment. The peak of 1962 would not be seen again until early 21st century. By 2016 number of organizations actively involved in R&D at level not seen since 1914.

95.

Baily, M. N. Pre-1962 drug development costs (baily 1972). Baily (1972) https://samizdathealth.org/wp-content/uploads/2020/12/hlthaff.1.2.6.pdf (1972)

Pre-1962: Average cost per new chemical entity (NCE) was $6.5 million (1980 dollars) Inflation-adjusted to 2024 dollars: $6.5M (1980) ≈ $22.5M (2024), using CPI multiplier of 3.46× Real cost increase (inflation-adjusted): $22.5M (pre-1962) → $2,600M (2024) = 116× increase Note: This represents the most comprehensive academic estimate of pre-1962 drug development costs based on empirical industry data Additional sources: https://samizdathealth.org/wp-content/uploads/2020/12/hlthaff.1.2.6.pdf

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96.

Think by Numbers. Pre-1962 physician-led clinical trials. Think by Numbers: How Many Lives Does FDA Save? https://thinkbynumbers.org/health/how-many-net-lives-does-the-fda-save/ (1966)

Pre-1962: Physicians could report real-world evidence directly 1962 Drug Amendments replaced "premarket notification" with "premarket approval", requiring extensive efficacy testing Impact: New regulatory clampdown reduced new treatment production by 70%; lifespan growth declined from  4 years/decade to  2 years/decade Drug Efficacy Study Implementation (DESI): NAS/NRC evaluated 3,400+ drugs approved 1938-1962 for safety only; reviewed >3,000 products, >16,000 therapeutic claims FDA has had authority to accept real-world evidence since 1962, clarified by 21st Century Cures Act (2016) Note: Specific "144,000 physicians" figure not verified in sources Additional sources: https://thinkbynumbers.org/health/how-many-net-lives-does-the-fda-save/ | https://www.fda.gov/drugs/enforcement-activities-fda/drug-efficacy-study-implementation-desi | http://www.nasonline.org/about-nas/history/archives/collections/des-1966-1969-1.html

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97.

GAO. 95% of diseases have 0 FDA-approved treatments. GAO https://www.gao.gov/products/gao-25-106774 (2025)

95% of diseases have no treatment Additional sources: https://www.gao.gov/products/gao-25-106774 | https://globalgenes.org/rare-disease-facts/

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98.

Oren Cass, Manhattan Institute. RECOVERY trial cost per patient. Oren Cass https://manhattan.institute/article/slow-costly-clinical-trials-drag-down-biomedical-breakthroughs (2023)

The RECOVERY trial, for example, cost only about $500 per patient... By contrast, the median per-patient cost of a pivotal trial for a new therapeutic is around $41,000. Additional sources: https://manhattan.institute/article/slow-costly-clinical-trials-drag-down-biomedical-breakthroughs

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99.

NHS England; Águas et al. RECOVERY trial global lives saved ( 1 million). NHS England: 1 Million Lives Saved https://www.england.nhs.uk/2021/03/covid-treatment-developed-in-the-nhs-saves-a-million-lives/ (2021)

Dexamethasone saved  1 million lives worldwide (NHS England estimate, March 2021, 9 months after discovery). UK alone: 22,000 lives saved. Methodology: Águas et al. Nature Communications 2021 estimated 650,000 lives (range: 240,000-1,400,000) for July-December 2020 alone, based on RECOVERY trial mortality reductions (36% for ventilated, 18% for oxygen-only patients) applied to global COVID hospitalizations. June 2020 announcement: Dexamethasone reduced deaths by up to 1/3 (ventilated patients), 1/5 (oxygen patients). Impact immediate: Adopted into standard care globally within hours of announcement. Additional sources: https://www.england.nhs.uk/2021/03/covid-treatment-developed-in-the-nhs-saves-a-million-lives/ | https://www.nature.com/articles/s41467-021-21134-2 | https://pharmaceutical-journal.com/article/news/steroid-has-saved-the-lives-of-one-million-covid-19-patients-worldwide-figures-show | https://www.recoverytrial.net/news/recovery-trial-celebrates-two-year-anniversary-of-life-saving-dexamethasone-result

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100.

National September 11 Memorial & Museum. September 11 attack facts. (2024)

2,977 people were killed in the September 11, 2001 attacks: 2,753 at the World Trade Center, 184 at the Pentagon, and 40 passengers and crew on United Flight 93 in Shanksville, Pennsylvania.

101.

World Bank. World bank singapore economic data. World Bank https://data.worldbank.org/country/singapore (2024)

Singapore GDP per capita (2023): $82,000 - among highest in the world Government spending: 15% of GDP (vs US 38%) Life expectancy: 84.1 years (vs US 77.5 years) Singapore demonstrates that low government spending can coexist with excellent outcomes Additional sources: https://data.worldbank.org/country/singapore

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102.

International Monetary Fund. IMF singapore government spending data. (2024)

Singapore government spending is approximately 15% of GDP This is 23 percentage points lower than the United States (38%) Despite lower spending, Singapore achieves excellent outcomes: - Life expectancy: 84.1 years (vs US 77.5) - Low crime, world-class infrastructure, AAA credit rating Additional sources: https://www.imf.org/en/Countries/SGP

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103.

World Health Organization. WHO life expectancy data by country. (2024)

Life expectancy at birth varies significantly among developed nations: Switzerland: 84.0 years (2023) Singapore: 84.1 years (2023) Japan: 84.3 years (2023) United States: 77.5 years (2023) - 6.5 years below Switzerland, Singapore Global average:  73 years Note: US spends more per capita on healthcare than any other nation, yet achieves lower life expectancy Additional sources: https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-life-expectancy-and-healthy-life-expectancy

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104.

CSIS. Smallpox eradication ROI. CSIS https://www.csis.org/analysis/smallpox-eradication-model-global-cooperation.

105.

PMC. Contribution of smoking reduction to life expectancy gains. PMC: Benefits Smoking Cessation Longevity https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447499/ (2012)

Population-level: Up to 14% (9% men, 14% women) of total life expectancy gain since 1960 due to tobacco control efforts Individual cessation benefits: Quitting at age 35 adds 6.9-8.5 years (men), 6.1-7.7 years (women) vs continuing smokers By cessation age: Age 25-34 = 10 years gained; age 35-44 = 9 years; age 45-54 = 6 years; age 65 = 2.0 years (men), 3.7 years (women) Cessation before age 40: Reduces death risk by  90% Long-term cessation: 10+ years yields survival comparable to never smokers, averts  10 years of life lost Recent cessation: <3 years averts  5 years of life lost Additional sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447499/ | https://www.cdc.gov/pcd/issues/2012/11_0295.htm | https://www.ajpmonline.org/article/S0749-3797(24)00217-4/fulltext | https://www.nejm.org/doi/full/10.1056/NEJMsa1211128

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106.

ICER. Value per QALY (standard economic value). ICER https://icer.org/wp-content/uploads/2024/02/Reference-Case-4.3.25.pdf (2024)

Standard economic value per QALY: $100,000–$150,000. This is the US and global standard willingness-to-pay threshold for interventions that add costs. Dominant interventions (those that save money while improving health) are favorable regardless of this threshold. Additional sources: https://icer.org/wp-content/uploads/2024/02/Reference-Case-4.3.25.pdf

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107.

GAO. Annual cost of u.s. Sugar subsidies. GAO: Sugar Program https://www.gao.gov/products/gao-24-106144

Consumer costs: $2.5-3.5 billion per year (GAO estimate) Net economic cost:  $1 billion per year 2022: US consumers paid 2X world price for sugar Program costs $3-4 billion/year but no federal budget impact (costs passed directly to consumers via higher prices) Employment impact: 10,000-20,000 manufacturing jobs lost annually in sugar-reliant industries (confectionery, etc.) Multiple studies confirm: Sweetener Users Association ($2.9-3.5B), AEI ($2.4B consumer cost), Beghin & Elobeid ($2.9-3.5B consumer surplus) Additional sources: https://www.gao.gov/products/gao-24-106144 | https://www.heritage.org/agriculture/report/the-us-sugar-program-bad-consumers-bad-agriculture-and-bad-america | https://www.aei.org/articles/the-u-s-spends-4-billion-a-year-subsidizing-stalinist-style-domestic-sugar-production/

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108.

World Bank. Swiss military budget as percentage of GDP. World Bank: Military Expenditure https://data.worldbank.org/indicator/MS.MIL.XPND.GD.ZS?locations=CH

2023: 0.70272% of GDP (World Bank) 2024: CHF 5.95 billion official military spending When including militia system costs:  1% GDP (CHF 8.75B) Comparison: Near bottom in Europe; only Ireland, Malta, Moldova spend less (excluding microstates with no armies) Additional sources: https://data.worldbank.org/indicator/MS.MIL.XPND.GD.ZS?locations=CH | https://www.avenir-suisse.ch/en/blog-defence-spending-switzerland-is-in-better-shape-than-it-seems/ | https://tradingeconomics.com/switzerland/military-expenditure-percent-of-gdp-wb-data.html

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109.

World Bank. Switzerland vs. US GDP per capita comparison. World Bank: Switzerland GDP Per Capita https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=CH

2024 GDP per capita (PPP-adjusted): Switzerland $93,819 vs United States $75,492 Switzerland’s GDP per capita 24% higher than US when adjusted for purchasing power parity Nominal 2024: Switzerland $103,670 vs US $85,810 Additional sources: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=CH | https://tradingeconomics.com/switzerland/gdp-per-capita-ppp | https://www.theglobaleconomy.com/USA/gdp_per_capita_ppp/

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110.

OECD. OECD government spending as percentage of GDP. (2024)

OECD government spending data shows significant variation among developed nations: United States: 38.0% of GDP (2023) Switzerland: 35.0% of GDP - 3 percentage points lower than US Singapore: 15.0% of GDP - 23 percentage points lower than US (per IMF data) OECD average: approximately 40% of GDP Additional sources: https://data.oecd.org/gga/general-government-spending.htm

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111.

OECD. OECD median household income comparison. (2024)

Median household disposable income varies significantly across OECD nations: United States: $77,500 (2023) Switzerland: $55,000 PPP-adjusted (lower nominal but comparable purchasing power) Singapore: $75,000 PPP-adjusted Additional sources: https://data.oecd.org/hha/household-disposable-income.htm

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112.

Wikipedia. Thalidomide scandal: Worldwide cases and mortality. Wikipedia https://en.wikipedia.org/wiki/Thalidomide_scandal

The total number of embryos affected by the use of thalidomide during pregnancy is estimated at 10,000, of whom about 40% died around the time of birth. More than 10,000 children in 46 countries were born with deformities such as phocomelia. Additional sources: https://en.wikipedia.org/wiki/Thalidomide_scandal

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113.

PLOS One. Health and quality of life of thalidomide survivors as they age. PLOS One https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210222 (2019)

Study of thalidomide survivors documenting ongoing disability impacts, quality of life, and long-term health outcomes. Survivors (now in their 60s) continue to experience significant disability from limb deformities, organ damage, and other effects. Additional sources: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210222

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114.

US Census Bureau. Historical world population estimates. US Census Bureau https://www.census.gov/data/tables/time-series/demo/international-programs/historical-est-worldpop.html

US Census Bureau historical estimates of world population by country and region (1950-2050). US population in 1960:  180 million of  3 billion worldwide (6%). Additional sources: https://www.census.gov/data/tables/time-series/demo/international-programs/historical-est-worldpop.html

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115.

FDA Study via NCBI. Trial costs, FDA study. FDA Study via NCBI https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248200/

Overall, the 138 clinical trials had an estimated median (IQR) cost of $19.0 million ($12.2 million-$33.1 million)... The clinical trials cost a median (IQR) of $41,117 ($31,802-$82,362) per patient. Additional sources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6248200/

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116.

GBD 2019 Diseases and Injuries Collaborators. Global burden of disease study 2019: Disability weights. The Lancet 396, 1204–1222 (2020)

Disability weights for 235 health states used in Global Burden of Disease calculations. Weights range from 0 (perfect health) to 1 (death equivalent). Chronic conditions like diabetes (0.05-0.35), COPD (0.04-0.41), depression (0.15-0.66), and cardiovascular disease (0.04-0.57) show substantial variation by severity. Treatment typically reduces disability weights by 50-80 percent for manageable chronic conditions.

117.

WHO. Annual global economic burden of alzheimer’s and other dementias. WHO: Dementia Fact Sheet https://www.who.int/news-room/fact-sheets/detail/dementia (2019)

Global cost: $1.3 trillion (2019 WHO-commissioned study) 50% from informal caregivers (family/friends,  5 hrs/day) 74% of costs in high-income countries despite 61% of patients in LMICs $818B (2010) → $1T (2018) → $1.3T (2019) - rapid growth Note: Costs increased 35% from 2010-2015 alone. Informal care represents massive hidden economic burden Additional sources: https://www.who.int/news-room/fact-sheets/detail/dementia | https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12901

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118.

JAMA Oncology. Annual global economic burden of cancer. JAMA Oncology: Global Cost 2020-2050 https://jamanetwork.com/journals/jamaoncology/fullarticle/2801798 (2020)

2020-2050 projection: $25.2 trillion total ($840B/year average) 2010 annual cost: $1.16 trillion (direct costs only) Recent estimate:  $3 trillion/year (all costs included) Top 5 cancers: lung (15.4%), colon/rectum (10.9%), breast (7.7%), liver (6.5%), leukemia (6.3%) Note: China/US account for 45% of global burden; 75% of deaths in LMICs but only 50.0% of economic cost Additional sources: https://jamanetwork.com/journals/jamaoncology/fullarticle/2801798 | https://www.nature.com/articles/d41586-023-00634-9

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119.

CDC. U.s. Chronic disease healthcare spending. CDC https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html

Chronic diseases account for  90% of U.S. healthcare spending ( $3.7T/year). Additional sources: https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html

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120.

Diabetes Care. Annual global economic burden of diabetes. Diabetes Care: Global Economic Burden https://diabetesjournals.org/care/article/41/5/963/36522/Global-Economic-Burden-of-Diabetes-in-Adults

2015: $1.3 trillion (1.8% of global GDP) 2030 projections: $2.1T-2.5T depending on scenario IDF health expenditure: $760B (2019) → $845B (2045 projected) 2/3 direct medical costs ($857B), 1/3 indirect costs (lost productivity) Note: Costs growing rapidly; expected to exceed $2T by 2030 Additional sources: https://diabetesjournals.org/care/article/41/5/963/36522/Global-Economic-Burden-of-Diabetes-in-Adults | https://doi.org/10.1016/S2213-8587(17)30097-9

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121.

CBO. The 2024 Long-Term Budget Outlook. https://www.cbo.gov/publication/60039 (2024).

122.

World Bank, Bureau of Economic Analysis. US GDP 2024 ($28.78 trillion). World Bank https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=US (2024)

US GDP reached $28.78 trillion in 2024, representing approximately 26% of global GDP. Additional sources: https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=US | https://www.bea.gov/news/2024/gross-domestic-product-fourth-quarter-and-year-2024-advance-estimate

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123.

Environmental Working Group. US farm subsidy database and analysis. Environmental Working Group https://farm.ewg.org/ (2024)

US agricultural subsidies total approximately $30 billion annually, but create much larger economic distortions. Top 10% of farms receive 78% of subsidies, benefits concentrated in commodity crops (corn, soy, wheat, cotton), environmental damage from monoculture incentivized, and overall deadweight loss estimated at $50-120 billion annually. Additional sources: https://farm.ewg.org/ | https://www.ers.usda.gov/topics/farm-economy/farm-sector-income-finances/government-payments-the-safety-net/

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124.

Drug Policy Alliance. The drug war by the numbers. (2021)

Since 1971, the war on drugs has cost the United States an estimated $1 trillion in enforcement. The federal drug control budget was $41 billion in 2022. Mass incarceration costs the U.S. at least $182 billion every year, with over $450 billion spent to incarcerate individuals on drug charges in federal prisons.

125.

International Monetary Fund. IMF fossil fuel subsidies data: 2023 update. (2023)

Globally, fossil fuel subsidies were $7 trillion in 2022 or 7.1 percent of GDP. The United States subsidies totaled $649 billion. Underpricing for local air pollution costs and climate damages are the largest contributor, accounting for about 30 percent each.

126.

Papanicolas, Irene et al. Health care spending in the united states and other high-income countries. Papanicolas et al. https://jamanetwork.com/journals/jama/article-abstract/2674671 (2018)

The US spent approximately twice as much as other high-income countries on medical care (mean per capita: $9,892 vs $5,289), with similar utilization but much higher prices. Administrative costs accounted for 8% of US spending vs 1-3% in other countries. US spending on pharmaceuticals was $1,443 per capita vs $749 elsewhere. Despite spending more, US health outcomes are not better. Additional sources: https://jamanetwork.com/journals/jama/article-abstract/2674671

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127.

Hsieh, C.-T. & Moretti, E. Housing constraints and spatial misallocation. American Economic Journal: Macroeconomics https://www.aeaweb.org/articles?id=10.1257/mac.20170388 (2019)

We quantify the amount of spatial misallocation of labor across US cities and its aggregate costs. Tight land-use restrictions in high-productivity cities like New York, San Francisco, and Boston lowered aggregate US growth by 36% from 1964 to 2009. Local constraints on housing supply have had enormous effects on the national economy. Additional sources: https://www.aeaweb.org/articles?id=10.1257/mac.20170388

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128.

Yale Budget Lab. The fiscal, economic, and distributional effects of all u.s. tariffs. (2025)

Accounting for all the 2025 US tariffs and retaliation implemented to date, the level of real GDP is persistently -0.6% smaller in the long run, the equivalent of $160 billion 2024$ annually.

129.

Tax Foundation. Tax compliance costs the US economy $546 billion annually. https://taxfoundation.org/data/all/federal/irs-tax-compliance-costs/ (2024)

Americans will spend over 7.9 billion hours complying with IRS tax filing and reporting requirements in 2024. This costs the economy roughly $413 billion in lost productivity. In addition, the IRS estimates that Americans spend roughly $133 billion annually in out-of-pocket costs, bringing the total compliance costs to $546 billion, or nearly 2 percent of GDP.

130.

Cook, C., Cole, G., Asaria, P., Jabbour, R. & Francis, D. P. Annual global economic burden of heart disease. International Journal of Cardiology https://www.internationaljournalofcardiology.com/article/S0167-5273(13)02238-9/abstract (2014)

Heart failure alone: $108 billion/year (2012 global analysis, 197 countries) US CVD: $555B (2016) → projected $1.8T by 2050 LMICs total CVD loss: $3.7T cumulative (2011-2015, 5-year period) CVD is costliest disease category in most developed nations Note: No single $2.1T global figure found; estimates vary widely by scope and year Additional sources: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001258

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131.

Source: US Life Expectancy FDA Budget 1543-2019 CSV. US life expectancy growth 1880-1960: 3.82 years per decade. (2019)

Pre-1962: 3.82 years/decade Post-1962: 1.54 years/decade Reduction: 60% decline in life expectancy growth rate Additional sources: https://ourworldindata.org/life-expectancy | https://www.mortality.org/ | https://www.cdc.gov/nchs/nvss/mortality_tables.htm

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132.

Source: US Life Expectancy FDA Budget 1543-2019 CSV. Post-1962 slowdown in life expectancy gains. (2019)

Pre-1962 (1880-1960): 3.82 years/decade Post-1962 (1962-2019): 1.54 years/decade Reduction: 60% decline Temporal correlation: Slowdown occurred immediately after 1962 Kefauver-Harris Amendment Additional sources: https://ourworldindata.org/life-expectancy | https://www.mortality.org/ | https://www.cdc.gov/nchs/nvss/mortality_tables.htm

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133.

Centers for Disease Control and Prevention. US life expectancy 2023. (2024)

US life expectancy at birth was 77.5 years in 2023 Male life expectancy: 74.8 years Female life expectancy: 80.2 years This is 6-7 years lower than peer developed nations despite higher healthcare spending Additional sources: https://www.cdc.gov/nchs/fastats/life-expectancy.htm

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134.

US Census Bureau. US median household income 2023. (2024)

US median household income was $77,500 in 2023 Real median household income declined 0.8% from 2022 Gini index: 0.467 (income inequality measure) Additional sources: https://www.census.gov/library/publications/2024/demo/p60-282.html

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135.

Manuel, D. U.s. Defense spending history: 100 years of military budgets. DaveManuel.com https://www.davemanuel.com/us-defense-spending-history-military-budget-data.php (2025)

US military spending in constant 2024 dollars: 1939 $29B (pre-WW2 baseline), 1940 $37B, 1944 $1,383B, 1945 $1,420B (peak), 1946 $674B, 1947 $176B, 1948 $117B, 2024 $886B. The post-WW2 demobilization cut spending 88% in two years (1945-1947). Current peacetime spending ($886B) is 30x the pre-WW2 baseline and 62% of peak WW2 spending, in inflation-adjusted dollars.

136.

Statista. US military budget as percentage of GDP. Statista https://www.statista.com/statistics/262742/countries-with-the-highest-military-spending/ (2024)

U.S. military spending amounted to 3.5% of GDP in 2024. In 2024, the U.S. spent nearly $1 trillion on its military budget, equal to 3.4% of GDP. Additional sources: https://www.statista.com/statistics/262742/countries-with-the-highest-military-spending/ | https://www.sipri.org/sites/default/files/2025-04/2504_fs_milex_2024.pdf

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137.

US Census Bureau. Number of registered or eligible voters in the u.s. US Census Bureau https://www.census.gov/newsroom/press-releases/2025/2024-presidential-election-voting-registration-tables.html (2024)

73.6% (or 174 million people) of the citizen voting-age population was registered to vote in 2024 (Census Bureau). More than 211 million citizens were active registered voters (86.6% of citizen voting age population) according to the Election Assistance Commission. Additional sources: https://www.census.gov/newsroom/press-releases/2025/2024-presidential-election-voting-registration-tables.html | https://www.eac.gov/news/2025/06/30/us-election-assistance-commission-releases-2024-election-administration-and-voting

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138.

U.S. Senate. Treaties. U.S. Senate https://www.senate.gov/about/powers-procedures/treaties.htm

The Constitution provides that the president ’shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two-thirds of the Senators present concur’ (Article II, section 2). Treaties are formal agreements with foreign nations that require two-thirds Senate approval. 67 senators (two-thirds of 100) must vote to ratify a treaty for it to take effect. Additional sources: https://www.senate.gov/about/powers-procedures/treaties.htm

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139.

Federal Election Commission. Statistical summary of 24-month campaign activity of the 2023-2024 election cycle. (2023)

Presidential candidates raised $2 billion; House and Senate candidates raised $3.8 billion and spent $3.7 billion; PACs raised $15.7 billion and spent $15.5 billion. Total federal campaign spending approximately $20 billion. Additional sources: https://www.fec.gov/updates/statistical-summary-of-24-month-campaign-activity-of-the-2023-2024-election-cycle/

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140.

OpenSecrets. Federal lobbying hit record $4.4 billion in 2024. (2024)

Total federal lobbying reached record $4.4 billion in 2024. The $150 million increase in lobbying continues an upward trend that began in 2016. Additional sources: https://www.opensecrets.org/news/2025/02/federal-lobbying-set-new-record-in-2024/

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141.

Columbia/NBER. Odds of a single vote being decisive in a u.s. Presidential election. Columbia/NBER: What Is the Probability Your Vote Will Make a Difference? https://sites.stat.columbia.edu/gelman/research/published/probdecisive2.pdf (2012)

National average: 1 in 60 million chance (2008 election analysis by Gelman, Silver, Edlin) Swing states (NM, VA, NH, CO):  1 in 10 million chance Non-competitive states: 34 states >1 in 100 million odds; 20 states >1 in 1 billion Washington DC: 1 in 490 billion odds Methodology: Probability state is necessary for electoral college win × probability state vote is tied Additional sources: https://sites.stat.columbia.edu/gelman/research/published/probdecisive2.pdf | https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1465-7295.2010.00272.x

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142.

Hutchinson and Kirk. Valley of death in drug development. (2011)

The overall failure rate of drugs that passed into Phase 1 trials to final approval is 90%. This lack of translation from promising preclinical findings to success in human trials is known as the "valley of death." Estimated 30-50% of promising compounds never proceed to Phase 2/3 trials primarily due to funding barriers rather than scientific failure. The late-stage attrition rate for oncology drugs is as high as 70% in Phase II and 59% in Phase III trials.

143.

DOT. DOT value of statistical life ($13.6M). DOT: VSL Guidance 2024 https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis (2024)

Current VSL (2024): $13.7 million (updated from $13.6M) Used in cost-benefit analyses for transportation regulations and infrastructure Methodology updated in 2013 guidance, adjusted annually for inflation and real income VSL represents aggregate willingness to pay for safety improvements that reduce fatalities by one Note: DOT has published VSL guidance periodically since 1993. Current $13.7M reflects 2024 inflation/income adjustments Additional sources: https://www.transportation.gov/office-policy/transportation-policy/revised-departmental-guidance-on-valuation-of-a-statistical-life-in-economic-analysis | https://www.transportation.gov/regulations/economic-values-used-in-analysis

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144.

PLOS ONE. Cost per DALY for vitamin a supplementation. PLOS ONE: Cost-effectiveness of "Golden Mustard" for Treating Vitamin A Deficiency in India (2010) https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0012046 (2010)

India: $23-$50 per DALY averted (least costly intervention, $1,000-$6,100 per death averted) Sub-Saharan Africa (2022): $220-$860 per DALY (Burkina Faso: $220, Kenya: $550, Nigeria: $860) WHO estimates for Africa: $40 per DALY for fortification, $255 for supplementation Uganda fortification: $18-$82 per DALY (oil: $18, sugar: $82) Note: Wide variation reflects differences in baseline VAD prevalence, coverage levels, and whether intervention is supplementation or fortification Additional sources: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0012046 | https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266495

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145.

UN News. Clean water & sanitation (LMICs) ROI. UN News https://news.un.org/en/story/2014/11/484032 (2014).

146.

PMC. Cost-effectiveness threshold ($50,000/QALY). PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC5193154/

The $50,000/QALY threshold is widely used in US health economics literature, originating from dialysis cost benchmarks in the 1980s. In US cost-utility analyses, 77.5% of authors use either $50,000 or $100,000 per QALY as reference points. Most successful health programs cost $3,000-10,000 per QALY. WHO-CHOICE uses GDP per capita multiples (1× GDP/capita = "very cost-effective", 3× GDP/capita = "cost-effective"), which for the US ( $70,000 GDP/capita) translates to $70,000-$210,000/QALY thresholds. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC5193154/ | https://pmc.ncbi.nlm.nih.gov/articles/PMC9278384/

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147.

Integrated Benefits Institute. Chronic illness workforce productivity loss. Integrated Benefits Institute 2024 https://www.ibiweb.org/resources/chronic-conditions-in-the-us-workforce-prevalence-trends-and-productivity-impacts (2024)

78.4% of U.S. employees have at least one chronic condition (7% increase since 2021) 58% of employees report physical chronic health conditions 28% of all employees experience productivity loss due to chronic conditions Average productivity loss: $4,798 per employee per year Employees with 3+ chronic conditions miss 7.8 days annually vs 2.2 days for those without Note: 28% productivity loss translates to roughly 11 hours per week (28% of 40-hour workweek) Additional sources: https://www.ibiweb.org/resources/chronic-conditions-in-the-us-workforce-prevalence-trends-and-productivity-impacts | https://www.onemedical.com/mediacenter/study-finds-more-than-half-of-employees-are-living-with-chronic-conditions-including-1-in-3-gen-z-and-millennial-employees/ | https://debeaumont.org/news/2025/poll-the-toll-of-chronic-health-conditions-on-employees-and-workplaces/

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148.

Sinn, M. P. The Invisible Graveyard: Quantifying the Mortality Cost of FDA Efficacy Lag. https://manual.warondisease.org/knowledge/appendix/invisible-graveyard.html (2025) doi:10.5281/zenodo.18356231

After proving a drug is safe, the FDA requires 8.2 years to prove it works before patients can access it. We estimate this delay cost 102 million deaths among people waiting for approved drugs (1962-2024). The human cost in death and disability of blocking good drugs is 3.07k higher than the cost of approving bad ones.

149.

Sinn, M. P. The 1% Treaty: Harnessing Greed to Eradicate Disease. https://manual.warondisease.org/knowledge/economics/1-pct-treaty-impact.html (2025) doi:10.5281/zenodo.18161560

6.65 thousand diseases have zero FDA-approved treatments; at current trial capacity, exploring them takes  443 years. Redirecting 1% of military spending scales capacity 12.3x, cutting the timeline to  36 years and preventing 10.7 billion deaths. At $0.00177/DALY, 50.3kx more cost-effective than the best existing interventions. Incentive Alignment Bonds make adoption politically viable.

150.

Sinn, M. P. Incentive Alignment Bonds: Making Public Goods Financially and Politically Profitable. https://manual.warondisease.org/knowledge/appendix/incentive-alignment-bonds-paper.html (2025) doi:10.5281/zenodo.18203221

Government spending is optimized for lobbying intensity, not net societal value. Programs with 100:1 benefit-cost ratios get billions while programs with negative returns get hundreds of billions. Incentive Alignment Bonds flip this by creating a capital pool that rewards politicians (via campaign support and post-office opportunities) for funding high-NSV programs over low-NSV alternatives. The result: public good becomes private profit for both investors and elected officials.

151.

Sinn, M. P. Wishocracy: Solving the Democratic Principal-Agent Problem Through Pairwise Preference Aggregation. https://manual.warondisease.org/knowledge/appendix/wishocracy-paper.html (2025) doi:10.5281/zenodo.18205881

Representative democracy suffers from an inescapable principal-agent problem where elected officials’ incentives diverge from citizen welfare. Wishocracy introduces RAPPA (Randomized Aggregated Pairwise Preference Allocation), which aggregates citizen preferences through cognitively tractable pairwise comparisons and creates accountability via Citizen Alignment Scores that channel electoral resources toward politicians who actually represent what citizens want.