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United States Efficiency Audit
A Systems Analysis of Recoverable Misallocation in U.S. Governance
Systems audit estimating an annual U.S. efficiency gap of $4.90T (95% CI: $3.62T-$6.50T), with $2.45T (95% CI: $1.81T-$3.25T) recoverable at OECD-median performance across direct spending waste, compliance burden, policy-induced GDP loss, and system inefficiency.
Abstract
This report applies systems engineering methodology to quantify allocative inefficiency in U.S. governance across four dysfunction categories: direct spending waste, compliance burden on the private sector, policy-induced GDP loss, and system inefficiency. Using Monte Carlo simulation across ten components with OECD benchmarking, we estimate an aggregate efficiency gap of $4.90T (95% CI: $3.62T-$6.50T) annually and recoverable capital of $2.45T (95% CI: $1.81T-$3.25T) if U.S. performance converges toward OECD median efficiency. This categorization distinguishes direct budget waste from broader economic dysfunction, each requiring different solution pathways. We also translate the efficiency gap into QALY and VSL-equivalent welfare terms for interpretability.
Keywords
allocative efficiency, systems analysis, federal spending, defense spending, healthcare administration, regulatory burden, OECD benchmarking, Monte Carlo simulation
Executive Summary
This audit applies engineering systems analysis to federal resource allocation. Rather than treating all “waste” as equivalent, we identify four distinct categories of dysfunction, each requiring different solutions:
Dysfunction Category Breakdown
| Category | Annual Cost | Mechanism | Solution Type |
|---|---|---|---|
| Direct Spending Waste | Federal budget misallocation | Budget reallocation | |
| Compliance Burden | Private sector regulatory friction | Simplification | |
| Policy-Induced GDP Loss | Market constraint policies | Policy reform | |
| System Inefficiency | Structural design failure | System redesign | |
| Total Efficiency Gap | $4.90T (95% CI: $3.62T-$6.50T) | (P5-P95 in variable output) | Multiple pathways |
This categorization matters: calling the entire efficiency gap “federal spending waste” invites justified criticism because only direct spending waste is budget allocations. The remainder reflects compliance burdens, policy-induced GDP losses, and system inefficiency that require different remedies.
Aggregate Metrics
| Metric | U.S. System | OECD Benchmark | Gap |
|---|---|---|---|
| Discretionary Efficiency | 75-85%a | ~34-44 pp | |
| Governance Efficiency (GDP) | 90-95%b | ~7-12 pp | |
| Recoverable Capital | $2.45T (95% CI: $1.81T-$3.25T)/year | N/A | if closed to OECD median |
| Human Cost (QALY equivalents) | 49.0 million QALYs (95% CI: 36.2 million QALYs-65.0 million QALYs) |
N/A | N/A |
| Human Cost (VSL equivalents) | 357 thousand people (95% CI: 264 thousand people-475 thousand people) |
N/A | N/A |
a OECD benchmark derived from comparative per-capita spending analysis: peer nations (Germany, France, UK, Canada, Australia) achieve comparable outcomes with lower discretionary waste rates95.
b OECD governance efficiency benchmark: peer nations achieve comparable median income growth and HALE outcomes with total governance-related losses of 5-10% of GDP rather than 17%.
Interpretation Note
The “human cost” figures are economic equivalents, not epidemiological mortality counts. Dividing the efficiency gap by VSL ($13.7M) or QALY threshold ($100K) yields a measure of foregone welfare, not literal deaths prevented.
Methodological Note: Subsystem losses are estimated independently and treated as additive. While some overlap may exist (e.g., housing costs affect health via stress, incarceration overlaps with drug enforcement), excluded categories (state/local inefficiency, implicit subsidies, behavioral effects) likely offset any potential overstatement.
The efficiency gap represents capital that could fund the 1% Treaty ($27.2B/year) 180:1 (95% CI: 133:1-239:1) times over.
System Specifications
Designed Function
The federal government’s designed function is to convert fiscal inputs (federal outlays and imposed compliance burdens) into citizen welfare. We measure this conversion efficiency using two terminal outcomes:
- After-tax real median income growth: measures economic welfare delivery
- Median healthy life years (HALE): measures health and longevity delivery
Why Two Metrics Are Sufficient
These two outputs capture all upstream factors that matter:
| Upstream Factor | Manifests in Income | Manifests in Healthy Life |
|---|---|---|
| Security/Safety | Crime costs, property loss | Violence, injury, chronic stress |
| Environment | Disaster costs, remediation | Respiratory disease, cancer |
| Freedom | Economic choice, mobility | Health decisions, reduced stress |
| Social Trust | Lower transaction costs | Mental health, social support |
| Education | Human capital, productivity | Health literacy |
| Infrastructure | Productivity, opportunity | Access to care, environmental health |
These are not omissions. They are upstream variables that manifest in terminal outcomes. Measuring income + health implicitly captures everything that affects citizen welfare.
Input-Output Measurement
Total System Input (federal outlays baseline for efficiency rating): $6.80T annually
Context (not additive):
- Federal revenue: $4.9T132
- State/local revenue attributable to federal mandates: ~$1.3T133
- Tax compliance burden: ~$546B (95% CI: $450B-$650B)115,134
Efficiency Metric: Output per dollar of input, benchmarked against OECD peer nations with comparable development levels.
For cross-country comparability, the efficiency rating uses federal outlays as the input baseline. Compliance burdens are treated as losses rather than additional inputs.
These contextual figures imply a combined fiscal and compliance footprint in the several-trillion-dollar range, but the efficiency rating uses federal outlays to keep the denominator comparable across OECD systems.
Methodology
Category Framework: Why Distinctions Matter
Not all inefficiency is created equal. A dollar misspent in the federal budget requires a different remedy than a dollar consumed by tax compliance or a dollar of GDP lost to zoning restrictions. We organize dysfunction into four categories by mechanism and solution pathway:
Direct Federal Spending Waste ($1.01T (95% CI: $790B-$1.30T))
Actual budget allocations flowing to low-value uses. This is traditional “government waste”: military overspend, corporate welfare, drug war enforcement, fossil fuel subsidies, agricultural subsidies. The solution is budget reallocation-redirect these dollars to higher-return uses without increasing total spending.
Think of military spending: the $615B (95% CI: $500B-$750B) “overspend” above strict deterrence baseline represents federal dollars that could fund disease eradication treaties instead of maintaining 750 overseas bases135.
Compliance Burden ($1.13T (95% CI: $775B-$1.58T))
Private sector resources consumed by government-imposed compliance requirements. Tax compliance costs $546B (95% CI: $450B-$650B) annually. This is not federal spending. The total includes 7.9 billion hours of lost productivity plus out-of-pocket filing costs. Regulatory red tape adds $580B (95% CI: $290B-$1T) in procedural friction without corresponding safety benefits.
The solution is simplification. Compare current U.S. tax system to the FairTax proposal: a national consumption tax would eliminate filing for most citizens, instantly recovering most of that compliance waste. Similarly, streamlining redundant regulations (keeping safety standards but removing paperwork friction) would recapture much of the regulatory burden.
Policy-Induced GDP Loss ($1.56T (95% CI: $1.05T-$2.18T))
Economic output that would exist but for policy constraints on markets. Housing/zoning restrictions prevent workers from moving to high-productivity cities, costing $1.40T (95% CI: $500B-$2T) annually in foregone GDP113. Tariffs cost another $160B (95% CI: $90B-$250B) through deadweight loss.
The solution is policy reform. Japan’s zoning system allows by-right development with minimal restrictions-the optimal comparison point showing what’s possible when government stops blocking private construction. Removing trade barriers would immediately expand economic output.
System Inefficiency ($1.20T (95% CI: $1T-$1.45T))
Fundamental design failures where the system architecture itself prevents efficiency. Healthcare exemplifies this: $1.20T (95% CI: $1T-$1.50T) in administrative waste not from bad management but from fragmented payment systems, lack of price transparency, and perverse incentives built into third-party payment structures.
The solution is system redesign. Compare to Singapore’s model: catastrophic coverage (government) + mandatory Health Savings Accounts (individual) + full price transparency. Or Switzerland’s regulated competition model where consumers choose insurers annually with real prices. Singapore achieves better outcomes at 4-5% of GDP, Switzerland at 11.8%, versus America’s 18%.
Why This Categorization?
Lumping all $4.90T (95% CI: $3.62T-$6.50T) together as “federal spending waste” is misleading and tactically foolish. Critics can correctly point out that zoning restrictions and tax compliance aren’t “federal waste” in the traditional sense. But separately categorized, each claim becomes defensible:
- $1.01T (95% CI: $790B-$1.30T) in direct budget waste? Documented line-by-line.
- $1.13T (95% CI: $775B-$1.58T) in compliance burden? Tax Foundation + Competitive Enterprise Institute data.
- $1.56T (95% CI: $1.05T-$2.18T) in GDP loss from bad policy? Peer-reviewed economics (Hsieh & Moretti, Yale Budget Lab).
- $1.20T (95% CI: $1T-$1.45T) in healthcare excess? JAMA, PGPF, international comparisons.
Each category points to specific remedies, making this analysis actionable rather than merely accusatory.
Engineering Loss Categories
We categorize resource losses using engineering terminology rather than political language. This framework adapts standard engineering efficiency analysis (where system losses are classified by mechanism rather than blame) to government resource allocation:
| Loss Category | Definition | Examples |
|---|---|---|
| Friction Losses | Administrative overhead exceeding minimum necessary (analogous to mechanical friction converting useful work to heat) | Healthcare billing complexity, tax compliance burden |
| Leakage | Fraud, improper payments, unverified expenditure | Medicare improper payments, unaudited DoD assets |
| Parasitic Load | Bureaucracy maintaining itself rather than serving function | Redundant agencies, regulatory capture |
| Transmission Loss | Efficiency loss in federal → state → local → citizen transfer | Grant administration overhead, unfunded mandates |
| Idle/Standby Loss | Capacity maintained but unused | Excess military bases, redundant weapons systems |
| Conversion Inefficiency | Policy intent failing to achieve stated outcome | Drug interdiction not reducing use |
| Negative Work | Policies producing net harm rather than benefit | Incarceration increasing recidivism |
Aggregate Efficiency Gap Calculation
The Aggregate Efficiency Gap (AEG) sums losses across all categories:
\[\text{AEG} = \sum_{i} \text{Friction}_i + \sum_{j} \text{Leakage}_j + \sum_{k} \text{Parasitic}_k + \sum_{l} \text{Transmission}_l + \sum_{m} \text{Idle}_m + \sum_{n} \text{Conversion}_n + \sum_{o} \text{Negative}_o\]
We employ Monte Carlo simulation to generate confidence intervals, recognizing uncertainty in loss estimates (particularly where data opacity exists, such as the DoD’s inability to audit 61% of assets).
Methodological Note: Additive Categories
Subsystem losses are estimated independently and treated as additive. While some overlap may exist (housing costs affect health via stress, incarceration overlaps with drug enforcement), excluded categories (state/local inefficiency, implicit subsidies, behavioral effects) likely offset any potential overstatement.
Valuation Standards
Direct Federal Spending Waste
Total: $1.01T (95% CI: $790B-$1.30T) annually
This category represents actual federal budget allocations flowing to demonstrably low-value uses. Unlike compliance burdens or GDP losses, these are dollars the federal government directly controls and could reallocate tomorrow with congressional action. The solution pathway is straightforward: budget reallocation from current uses to higher-return alternatives.
Components
| Component | Annual Cost | Optimal Comparison |
|---|---|---|
| Military overspend | Strict Deterrence doctrine ($285B baseline) | |
| Corporate welfare | Zero subsidies (market allocation) | |
| Drug war | Portugal decriminalization model | |
| Fossil fuel subsidies | Zero subsidies (market pricing) | |
| Agricultural subsidies | New Zealand model (ended all farm subsidies 1984)136 |
Every dollar here comes from taxpayers and goes somewhere. The question is not whether to spend it, but what to spend it on. Redirecting $615B (95% CI: $500B-$750B) from maintaining 750 overseas bases to funding disease eradication treaties doesn’t require new revenue-just different priorities.
Platonic Ideal: New Zealand eliminated all agricultural subsidies in 1984136. Farm productivity increased. Why? Subsidies had encouraged marginal land cultivation and overproduction. Without them, farmers specialized in comparative advantages. The U.S. spends $75B (95% CI: $50B-$120B) annually doing precisely what New Zealand proved counterproductive.
Detailed subsystem analysis follows in: Subsystem Audit: Defense, Subsystem Audit: Justice, Subsystem Audit: Subsidies
Compliance Burden on Private Sector
Total: $1.13T (95% CI: $775B-$1.58T) annually
These costs don’t appear in the federal budget. They represent private sector resources consumed by government-imposed requirements: calculating taxes, filing paperwork, navigating regulatory red tape. The solution pathway is simplification-streamlining processes to reduce friction while preserving necessary functions.
Components
| Component | Annual Cost | Optimal Comparison |
|---|---|---|
| Tax compliance | FairTax system (consumption tax, no filing) | |
| Regulatory red tape | Evidence-based regulation (eliminate procedural friction) |
The Tax Compliance Absurdity: Americans spend 7.9 billion hours annually calculating taxes115. That’s $546B (95% CI: $450B-$650B) in total compliance costs. What do we get for this? The privilege of determining what we owe the government-a calculation the IRS must verify anyway.
Platonic Ideal: FairTax System
The FairTax proposes a national retail sales tax replacing income/payroll/corporate taxes. Most citizens would never file taxes. Businesses collect at point of sale (like state sales taxes already do). Complexity collapses from 75,000-page tax code to a single rate.
Would this be optimal? Perhaps not perfectly-consumption taxes have their own distortions. But compared to the current system where middle-class families spend 13 hours filing returns and $273 on preparation115, almost any simplification recovers massive waste.
The regulatory red tape figure ($580B (95% CI: $290B-$1T)) represents procedural friction without corresponding safety benefits. We’re not arguing against workplace safety regulations or environmental standards. We’re identifying paperwork requirements that don’t improve outcomes-the administrative equivalent of demanding triplicate forms in three different formats.
Detailed subsystem analysis follows in: Subsystem Audit: Regulatory and Tax Compliance
Policy-Induced GDP Loss
Total: $1.56T (95% CI: $1.05T-$2.18T) annually
These losses represent economic output that would exist but for government policy constraining markets. Not spending, not compliance-forgone GDP. Workers who can’t move to high-productivity cities because housing is illegal to build. Trade gains evaporated by tariffs. The solution pathway is policy reform: remove the constraints.
Components
| Component | Annual Cost | Optimal Comparison |
|---|---|---|
| Housing/zoning restrictions | Japan’s by-right zoning system | |
| Tariffs | Free trade (zero tariffs) |
The Zoning Stranglehold: Government prevents builders from building where people want to live. High-productivity cities like San Francisco and New York have demand for millions more housing units. Zoning restrictions make construction illegal. Result? Workers stuck in Akron when they would be more productive in San Jose. Hsieh & Moretti113 estimate large GDP losses from restrictive zoning in high-productivity cities; subsequent revisions lowered the point estimate substantially. We use a conservative annual cost of $1.40T (95% CI: $500B-$2T).
Platonic Ideal: Japan’s Zoning System
Japan allows by-right development with minimal restrictions. National zoning law supersedes local NIMBY vetoes. Outcome? Tokyo, a city of 14 million, has stable housing costs despite population growth137. Build more houses, prices don’t spike. Obvious? Apparently not in America, where cities prefer aesthetic purity to economic dynamism.
Tariffs: The Yale Budget Lab estimates U.S. tariffs reduce long-run GDP by 0.6%, approximately $160B (95% CI: $90B-$250B) annually114. Tariffs protect specific industries while raising prices for everyone else. The costs are diffuse (everyone pays more for washing machines), the benefits concentrated (appliance manufacturers lobby to keep protection). Classic public choice failure.
Detailed subsystem analysis follows in: Subsystem Audit: Regulatory and Tax Compliance, Subsystem Audit: Subsidies
System Inefficiency
Total: $1.20T (95% CI: $1T-$1.45T) annually
This category represents fundamental design failures where the system architecture itself prevents efficiency. Not bad management-bad structure. Healthcare exemplifies this: fragmented payment systems, zero price transparency, third-party payment everywhere, perverse incentives baked into the model. The solution pathway is system redesign: change the architecture.
Components
| Component | Annual Cost | Optimal Comparison |
|---|---|---|
| Healthcare administration | Singapore model (catastrophic + HSAs) Switzerland model (regulated competition) |
The Healthcare Labyrinth: The U.S. spends 18% of GDP on healthcare-$5.3 trillion-and gets worse outcomes than nations spending 10-11%138. The delta isn’t care quality. It’s administrative friction: billing complexity, fragmented systems, no price transparency.
Why This is System Inefficiency, Not Direct Spending Waste: Healthcare’s $1.20T (95% CI: $1T-$1.50T) waste isn’t federal spending that could be reallocated. It’s private spending (55% of total healthcare) flowing through a systemically broken structure. You can’t “budget reallocate” your way out of third-party payment incentive problems.
Platonic Ideals: Singapore and Switzerland
Singapore (most cost-efficient): Catastrophic coverage (government) + mandatory Health Savings Accounts (individual) + full price transparency. Patients pay directly for routine care, see real prices, make cost-conscious decisions. Government covers disasters. Result: 4-5% of GDP on healthcare, outcomes matching or beating the U.S.139
Switzerland (more politically feasible): Universal coverage through regulated private competition. Citizens choose insurers annually. Real price signals. Insurers compete on efficiency. Result: 11.8% of GDP (2023), excellent outcomes140.
Singapore is clearly superior on cost-efficiency (4-5% vs 11.8% of GDP), both achieving comparable health outcomes. But Switzerland’s model may be more politically viable in Western democracies-it’s closer to existing insurance systems, just with actual competition and price transparency.
Both systems use competitive market mechanisms rather than single-payer rationing. The U.S. has neither competition nor single-payer-we have the worst of both: third-party payment hiding prices, employer-based insurance trapping workers, no cost transparency anywhere.
Singapore spends less than half what Switzerland does (as percentage of GDP) while achieving similar outcomes. That’s the optimal target. Switzerland demonstrates you can achieve excellent outcomes at 11.8% of GDP with private competition-still 35% cheaper than America’s 18%.
Detailed subsystem analysis follows in: Subsystem Audit: Healthcare Administration
Subsystem Cross-Reference
The following subsystem audits provide detailed component breakdowns. Each subsystem maps to one or more dysfunction categories:
| Subsystem | Primary Category | Components |
|---|---|---|
| Defense | Direct Spending Waste | Military overspend ($615B (95% CI: $500B-$750B)) |
| Healthcare Administration | System Inefficiency | Healthcare system waste ($1.20T (95% CI: $1T-$1.50T)) |
| Justice and Prohibition | Direct Spending Waste | Drug war ($90B (95% CI: $60B-$150B)) |
| Regulatory and Tax Compliance | Compliance Burden + Policy-Induced GDP Loss | Tax compliance ($546B (95% CI: $450B-$650B)), Regulatory red tape ($580B (95% CI: $290B-$1T)), Housing/zoning ($1.40T (95% CI: $500B-$2T)) |
| Subsidies and Transfers | Direct Spending Waste + Policy-Induced GDP Loss | Corporate welfare ($181B (95% CI: $150B-$220B)), Fossil fuel subsidies ($50B (95% CI: $30B-$80B)), Agricultural subsidies ($75B (95% CI: $50B-$120B)), Tariffs ($160B (95% CI: $90B-$250B)) |
Subsystem Audit: Defense
In the core model, defense contributes $615B (95% CI: $500B-$750B) annually through military overspend above the strict deterrence baseline. The Department of Defense operates as the largest discretionary expenditure node, with annual spending of approximately $900 billion141. Current spending exceeds the next nine nations combined142.
Loss Category: Leakage (Audit Failure)
In November 2024, the Pentagon failed its seventh consecutive audit143. The DoD was unable to account for 61-63% of its $3.8 trillion in assets (dollar-weighted)144, approximately $2.5 trillion in property, equipment, and inventory with unknown location, condition, or existence status.
The mechanism: fragmented logistics systems where contractors record inventory data, creating principal-agent misalignment145. Without verified asset ledgers, the DoD regularly purchases parts it already owns but cannot locate.
Estimated leakage: Assuming 5% inventory shrinkage on unaccounted assets = $125 billion stock, plus ongoing logistics inefficiency.
Loss Category: Conversion Inefficiency (F-35 Program)
The F-35 program exemplifies “concurrency”: producing aircraft before design completion. Results:
- Lifetime sustainment cost: increased from $1.1T (2018) to $1.58T (2023)146
- Availability rates: declining despite 44% cost increase146
- 2024 delivery delays: average 238 days late147
Estimated conversion inefficiency: $15-20 billion annually in defect remediation and unflown flight hours.
Loss Category: Idle/Standby (Overseas Basing)
The U.S. maintains approximately 750 military bases in over 80 countries135, architecture designed for 1945 geopolitics.
- Direct base maintenance: $55-80 billion annually135
- Personnel premium: $10,000-$40,000 per person above domestic stationing148
The Quincy Institute estimates that shifting to “Active Denial” strategy (asymmetric defense via drones, missiles, mines rather than power projection platforms) could achieve equivalent deterrence at $75 billion annual savings by 2035149.
Loss Category: Parasitic (Strategic Misalignment)
The “Overmatch” doctrine requires dominance in every theater simultaneously, creating unlimited spending requirements. The Congressional Budget Office projects defense costs will rise to $965 billion by 2039150, driven by this refusal to rationalize legacy commitments. A rational optimization would focus on:
- Robust nuclear deterrent (submarine-based leg sufficient)
- Naval denial capabilities
- Asymmetric defense posture
Cutting the redundant ICBM leg and reducing bomber procurement would save $15-20 billion annually151.
Defense Subsystem Summary
| Measure | Value |
|---|---|
| Core modeled defense contribution |
The mechanism-specific estimates above (audit leakage, F-35 conversion losses, overseas basing, strategic misalignment) explain drivers of this overspend and should not be added as separate totals.
Subsystem Audit: Healthcare Administration
In the core model, healthcare system inefficiency contributes $1.20T (95% CI: $1T-$1.50T) annually. U.S. healthcare consumes ~18% of GDP ($5.3 trillion)152 yet delivers health outcomes inferior to peer nations spending 10-11% of GDP138. The delta is not care quality. It is administrative friction.
Loss Category: Friction (Administrative Overhead)
The U.S. spends approximately $1,000 more per person on administrative costs than the average wealthy OECD country138. With 335 million population:
Administrative excess: ~$335 billion annually
A 2020 study found U.S. administrative spending at 34.2% of health expenditures versus 17% in Canada153. This overhead does not improve outcomes. It diverts resources from care to paperwork.
Loss Category: Leakage (Medicare Advantage Upcoding)
Medicare Advantage functions as a subsidy mechanism via “upcoding”: making patients appear sicker than they are to increase capitated payments.
Loss Category: Leakage (Improper Payments)
GAO estimates $162 billion in improper payments government-wide in 2024, with 75% concentrated in Medicare and Medicaid157.
- Medicare Fee-for-Service: ~7.4% improper payment rate
- Medicaid: often higher
Private financial networks operate with fraud rates orders of magnitude lower.
Healthcare Subsystem Summary
| Measure | Value |
|---|---|
| Core modeled healthcare inefficiency |
The administrative and payment-fraud estimates above are key mechanisms within this broader system-level inefficiency.
Subsystem Audit: Justice and Prohibition
In the core model, justice and prohibition contribute $90B (95% CI: $60B-$150B) annually through direct drug war spending and associated direct losses. Broader incarceration externalities remain substantial but are treated as contextual estimates here to avoid overlap with other modeled categories.
Loss Category: Conversion Inefficiency (Drug Prohibition)
The federal drug control budget for 2024: nearly $45 billion158. Total expenditure since 1971: over $1 trillion159.
Outcome: Drug use rates unchanged or increased160. The market has innovated toward more potent compounds (fentanyl). This is a direct consequence of the “Iron Law of Prohibition,” where interdiction shifts production to higher-value-per-weight products.
Despite state legalization, federal marijuana enforcement continues at approximately $3.6 billion annually161, pure deadweight loss on activity that is economically productive in legal jurisdictions.
Loss Category: Negative Work (Mass Incarceration)
The U.S. incarcerates at rates unmatched in the developed world, removing prime-age workers from the labor force and degrading human capital.
Direct system costs: $80.7 billion in public corrections expenditure162
Economic burden estimates:
- FWD.us: $348 billion annually (lost wages, family costs)163
- Comprehensive burden (including health effects, child welfare): $1 trillion annually164
Lost lifetime earnings per incarcerated person: approximately $500,000162. The system fails at rehabilitation. High recidivism rates mean the “correctional” investment yields defective output.
Loss Category: Leakage (Civil Asset Forfeiture)
Civil asset forfeiture allows property seizure without criminal conviction. FY 2024 Treasury Forfeiture Fund: $2.26 billion processed165.
This mechanism incentivizes revenue-generating enforcement over public safety, introduces property rights uncertainty, and constitutes wealth transfer from productive activity to bureaucracy.
Justice Subsystem Summary
| Measure | Value |
|---|---|
| Core modeled justice/prohibition contribution |
Note: The incarceration burden estimates above reflect broader societal externalities and are presented as contextual evidence rather than additive components in the core aggregate model.
Subsystem Audit: Regulatory and Tax Compliance
[Compliance Burden + Policy-Induced GDP Loss]
In the core model, this subsystem maps to three major components: tax compliance ($546B (95% CI: $450B-$650B)), regulatory red tape ($580B (95% CI: $290B-$1T)), and housing/zoning misallocation ($1.40T (95% CI: $500B-$2T)). Together they represent a substantial unrecorded subtraction from national output.
Loss Category: Friction (Tax Compliance)
Americans spend 7.1-7.9 billion hours annually complying with the tax code134.
Total compliance cost: $546B (95% CI: $450B-$650B) annually (Tax Foundation estimate)115,134
This is approximately 1.9% of GDP, exceeding total corporate income tax revenue. The labor produces nothing but compliance documentation.
Benchmark comparison: Thirty-six countries use “Return-Free Filing” where governments pre-fill returns with data already in their possession166. The U.S. tax preparation lobby (Intuit, H&R Block) has successfully lobbied to prevent this simplification167, effectively taxing Americans an additional $500+ billion in lost time and fees to protect a rent-seeking industry.
Loss Category: Friction (Housing/Zoning Misallocation)
Local zoning regulations artificially restrict housing supply in high-productivity cities, preventing labor mobility to productive clusters.
Spatial misallocation cost: Moderate estimates imply losses on the order of $1.40T (95% CI: $500B-$2T) annually168,169. The full range spans $500B to $2T depending on modeling assumptions.
Note: The original Hsieh-Moretti (2019) estimate of 36% GDP growth reduction was substantially revised downward by Greaney (2023). The figure used here reflects a moderate annualized estimate rather than the original upper bound.
Federal policy subsidizes this dysfunction via mortgage interest deductions and infrastructure grants without upzoning requirements.
Loss Category: Idle (NEPA Permitting Delays)
The National Environmental Policy Act forces infrastructure projects into multi-year review. Average Environmental Impact Statement: 4.5 years.
Delay costs: $100-140 billion annually in lost returns and capital efficiency170.
NEPA creates a “Green Paradox”: delaying clean energy projects (transmission, wind, geothermal) more than fossil fuel projects, undermining stated policy goals.
Loss Category: Parasitic (Jones Act)
The Jones Act requires domestic shipping on U.S.-built, U.S.-crewed vessels. Results:
Regulatory Subsystem Summary
| Core Modeled Component | Value |
|---|---|
| Tax compliance | |
| Regulatory red tape | |
| Housing/zoning misallocation |
NEPA and Jones Act estimates above are additional policy frictions discussed for context and are not separately added to the core model total here.
Subsystem Audit: Subsidies and Transfers
[Direct Spending Waste + Policy-Induced GDP Loss]
In the core model, this subsystem includes corporate welfare ($181B (95% CI: $150B-$220B)), fossil fuel subsidies ($50B (95% CI: $30B-$80B)), agricultural subsidies ($75B (95% CI: $50B-$120B)), and tariff-related GDP loss ($160B (95% CI: $90B-$250B)).
Loss Category: Parasitic (Fossil Fuel Subsidies)
Direct annual subsidies to fossil fuel companies: $10-52 billion173.
This represents capital transfer to a mature, profitable industry, artificially lowering carbon-intensive energy costs relative to alternatives and slowing energy transition.
Loss Category: Parasitic (Agricultural Subsidies)
Agricultural subsidies in 2024: $9.3-30 billion174. Distribution is regressive. Top 10% of recipients received 65% of payments in 2024175.
The subsidy structure incentivizes overproduction of corn and soy, which form the backbone of the processed food diet driving the obesity epidemic. This creates a Waste Feedback Loop: taxpayer funds subsidize production of cheap calories that make the population sick, requiring additional taxpayer funds to treat the resulting chronic disease (see Healthcare subsystem). Agricultural policy thus amplifies healthcare inefficiency.
Loss Category: Negative Work (Tariffs and Corporate Welfare)
Corporate welfare: Cato Institute tallies $181 billion annually in grants, loans, and credits to specific businesses176.
Tariff deadweight loss: Yale Budget Lab estimates U.S. tariffs reduce long-run GDP by about 0.6%, equivalent to $160B (95% CI: $90B-$250B) annually114.
Subsidies Subsystem Summary
| Core Modeled Component | Value |
|---|---|
| Corporate welfare | |
| Fossil fuel subsidies | |
| Agricultural subsidies | |
| Tariff-related GDP loss |
Aggregate Efficiency Calculation
Monte Carlo Simulation Parameters
We model Total Efficiency Gap as the sum of ten core components, grouped into four categories, with Monte Carlo simulation accounting for correlated uncertainties.
| Category | Mean (Model Output) | Notes |
|---|---|---|
| Direct Spending Waste | Budget allocations that can be reallocated | |
| Compliance Burden | Private-sector compliance friction | |
| Policy-Induced GDP Loss | Foregone output from policy constraints | |
| System Inefficiency | Structural design failures | |
| Total Efficiency Gap | $4.90T (95% CI: $3.62T-$6.50T) | Aggregate modeled loss |
Simulation Results
Aggregate Efficiency Gap (FY 2024-2025):
| Percentile | Estimate |
|---|---|
| Mean (Central) |
Note: The P5-P95 confidence interval is embedded in the variable output. Category means sum to the aggregate total, with Monte Carlo simulation modeling correlated uncertainties across components.
As percentage of GDP: 17% (95% CI: 12.6%-22.6%)
Category Breakdown:
| Category | Annual Cost | Solution Type |
|---|---|---|
| Direct Spending Waste | Budget reallocation | |
| Compliance Burden | Simplification | |
| Policy-Induced GDP Loss | Policy reform | |
| System Inefficiency | System redesign | |
| Total | $4.90T (95% CI: $3.62T-$6.50T) | Multiple pathways |
This breakdown clarifies that only direct spending waste represents traditional “federal budget waste” subject to reallocation. The majority reflects broader economic dysfunction requiring simplification (compliance burden), policy reform (policy-induced GDP loss), or structural redesign (system inefficiency).
Subsystem Uncertainty Distributions
The following figures show Monte Carlo distributions for key subsystem loss estimates:
This chart shows the assumed probability distribution for this parameter. The shaded region represents the 95% confidence interval where we expect the true value to fall.
This chart shows the assumed probability distribution for this parameter. The shaded region represents the 95% confidence interval where we expect the true value to fall.
This chart shows the assumed probability distribution for this parameter. The shaded region represents the 95% confidence interval where we expect the true value to fall.
This chart shows the assumed probability distribution for this parameter. The shaded region represents the 95% confidence interval where we expect the true value to fall.
Efficiency Rating Calculation
We report two efficiency metrics using different denominators, each answering a distinct question:
Discretionary Efficiency (Cat 1 waste vs. discretionary spending): What fraction of fungible federal spending avoids direct waste?
\[ \begin{gathered} E_{US,disc} \\ = 1 - \frac{W_{cat1}}{Spending_{fed}} \\ = 1 - \frac{\$1.01T}{\$1.7T} \\ = 40.5\% \\[0.5em] \text{where } W_{cat1} \\ = W_{military} + W_{corporate} + W_{drugs} \\ + W_{fossil} + W_{agriculture} \\ = \$615B + \$181B + \$90B + \$50B + \$75B \\ = \$1.01T \end{gathered} \]
This metric uses discretionary spending ($1.7T) as the denominator because Cat 1 items (military overspend, corporate welfare, drug war, fossil/ag subsidies) are fungible policy choices. Some Cat 1 items (farm subsidies, tax expenditures) are technically mandatory or off-budget but represent actionable policy choices.
Governance Efficiency (total waste vs. GDP): How much of the economy is consumed by all four categories of governance dysfunction?
\[ \begin{gathered} E_{US,GDP} = 1 - \frac{W_{total,US}}{USGDP} = 1 - \frac{\$4.9T}{\$28.8T} = 83\% \\[0.5em] \text{where } W_{total,US} = W_{raw,US} \times US = \$4.9T \times 1 = \$4.9T \\[0.5em] \text{where } W_{raw,US} \\ = W_{health} + W_{housing} + W_{military} \\ + W_{regulatory} + W_{tax} + W_{corporate} \\ + W_{tariffs} + W_{drugs} + W_{fossil} \\ + W_{agriculture} \\ = \$1.2T + \$1.4T + \$615B + \$580B + \$546B \\ + \$181B + \$160B + \$90B + \$50B + \$75B \\ = \$4.9T \end{gathered} \]
This broader metric captures all dysfunction categories (direct spending waste, compliance burden, policy-induced GDP loss, system inefficiency) relative to total economic output.
OECD benchmark: Peer nations achieve comparable outcomes with discretionary waste rates of 15-25% and total governance-related losses of 5-10% of GDP.
Human Cost Quantification (Economic Equivalents)
To contextualize the efficiency gap in human terms, we apply standard valuation thresholds. These are economic equivalents, not epidemiological mortality counts.
Using VSL ($13.7M):
VSL-Equivalents = $4.90T (95% CI: $3.62T-$6.50T) / $13.7M = 357 thousand people (95% CI: 264 thousand people-475 thousand people)
Using QALY threshold ($100K):
QALY-Equivalents = $4.90T (95% CI: $3.62T-$6.50T) / $100K = 49.0 million QALYs (95% CI: 36.2 million QALYs-65.0 million QALYs)
Interpretation: The efficiency gap represents foregone welfare equivalent to 49.0 million QALYs (95% CI: 36.2 million QALYs-65.0 million QALYs) annually. This does not mean 357 thousand people (95% CI: 264 thousand people-475 thousand people) die from inefficiency. Rather, the misallocated resources could have purchased health improvements of that magnitude if deployed at cost-effectiveness thresholds used in medical decision-making.
Reallocation Potential
If U.S. efficiency improved to OECD median (80%), approximately $2.45T (95% CI: $1.81T-$3.25T) annually becomes available for reallocation.
For scale, the total efficiency gap ($4.90T (95% CI: $3.62T-$6.50T)/year) implies the following coverage estimates.
Context Comparisons
| Initiative | Cost Benchmark | Comparison to Annual Gap |
|---|---|---|
| 1% Treaty funding | 180:1 (95% CI: 133:1-239:1) covered | |
| Global disease R&D (current) | $150B177 | Annual gap remains multiple times larger |
| U.S. infrastructure backlog | $2.6T total178 | Comparable in scale to one year of the gap |
| Global poverty elimination | ~$175B179 | Annual gap remains multiple times larger |
| Complete grid decarbonization | $100B/year180 | Annual gap remains multiple times larger |
The efficiency gap is not abstract accounting. It represents real capacity currently unavailable for health, infrastructure, and security improvements.
Opportunity Cost in Healthy Life Years
Each dollar of wasteful spending has a concrete human cost: it could have funded pragmatic clinical trials that accelerate treatment discovery. Table 1 converts each waste category into DALYs that could be averted if redirected to ubiquitous pragmatic trials.
| Category | Annual Waste | x Treaty Funding |
|---|---|---|
| Housing & Zoning Restrictions | $1400B | 64.3x |
| Healthcare Inefficiency | $1200B | 55.1x |
| Military Overspend | $615B | 28.3x |
| Regulatory Red Tape | $580B | 26.7x |
| Tax Compliance Burden | $546B | 25.1x |
| Corporate Welfare | $181B | 8.3x |
| Tariffs (GDP Loss) | $160B | 7.4x |
| Drug War | $90B | 4.1x |
| Agricultural Subsidies | $75B | 3.4x |
| Fossil Fuel Subsidies | $50B | 2.3x |
| Total | $4.9T | 225x |
Structural Factors
Why do these losses persist despite apparent obviousness? Several structural factors explain system inertia:
Severed Feedback Loops
Government programs lack market feedback mechanisms. A private firm losing $210 billion annually on inefficient logistics would face bankruptcy. Federal agencies face no equivalent selection pressure.
Principal-Agent Misalignment
Those administering programs (bureaucrats, contractors) have incentives misaligned with program objectives. Contractors profit from complexity; administrators expand headcount regardless of output.
Measurement Failure
Current accounting measures expenditure, not utility. A dollar spent equals a dollar of “activity” regardless of outcome. Without output measurement, optimization is impossible.
Monopoly Dynamics
Government services typically face no competition. Without competitive pressure, innovation lags and costs inflate. This is the standard monopoly outcome.
Time Horizon Mismatch
Political cycles (2-4 years) misalign with infrastructure and policy cycles (10-30 years). Long-term efficiency investments lose to short-term visible spending.
Confidence Intervals and Limitations
Estimate Confidence by Subsystem
| Subsystem | Data Quality | Confidence |
|---|---|---|
| Healthcare Admin | High (OECD comparisons) | High |
| Tax Compliance | High (IRS data) | High |
| Defense Audit | Low (61% unaccounted) | Medium |
| Incarceration | Medium (direct costs clear, indirect estimated) | Medium |
| Housing Misallocation | Medium (model-dependent) | Medium |
| Drug War Opportunity Cost | Low (counterfactual) | Low |
What This Analysis Excludes
- State/local inefficiency beyond federal mandates
- Implicit subsidies (unpriced externalities)
- Intergenerational costs (debt burden on future)
- Second-order behavioral effects
- International competitiveness losses
Including these factors would increase the efficiency gap estimate substantially.
Methodological Limitations
- Counterfactual uncertainty: Some estimates require modeling what “would have happened” under alternative policies
- Attribution challenges: Separating federal from state/local effects
- Valuation debates: VSL and QALY thresholds vary by methodology
- Data opacity: DoD audit failures mean some estimates are necessarily imprecise
See Also
For global perspective on governance efficiency and broader opportunity costs of political dysfunction, see The Political Dysfunction Tax, which extends this analysis to estimate a Global Governance Efficiency Score of 30-52% and identifies $101 trillion in annual unrealized potential from suppressed health innovation, migration restrictions, and lead poisoning remediation delays.
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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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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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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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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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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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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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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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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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FDA. FDA GRAS list count ( 570-700). FDA https://www.fda.gov/food/generally-recognized-safe-gras/gras-notice-inventory
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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/
.30.
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
.31.
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
.32.
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
.33.
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/
.34.
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/
.35.
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
.36.
Think by Numbers. Lost human capital due to war ($270B annually). Think by Numbers: War Costs $74 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/
.37.
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/
.38.
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
.39.
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
.40.
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
.41.
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.
42.
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.
43.
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.
44.
Sinn, M. P. The Political Dysfunction Tax. https://political-dysfunction-tax.warondisease.org (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.
45.
Trials, A. C. 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
.46.
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
.47.
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.
48.
SIPRI. Global military spending ($2.72T, 2024). SIPRI https://www.sipri.org/publications/2025/sipri-fact-sheets/trends-world-military-expenditure-2024 (2025).
49.
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.
50.
IQVIA, I. reports: 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.
51.
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
.52.
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
.53.
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/
.54.
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/
.55.
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
.56.
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
.57.
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
.58.
Vaccines, M. 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
.59.
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).
60.
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
.61.
Institute, S. I. P. R. Trends in world military expenditure, 2023. (2024).
62.
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.
63.
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/
.64.
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/
.65.
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/
.66.
Institute, M. 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/
.67.
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/
.68.
CSDD, T. 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.
69.
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
.70.
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.
71.
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/
.72.
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
.73.
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
.74.
Ramsberg J, P. 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 $27. Additional sources: https://pmc.ncbi.nlm.nih.gov/articles/PMC6508852/
.75.
WHO. Polio vaccination ROI. WHO https://www.who.int/news-room/feature-stories/detail/sustaining-polio-investments-offers-a-high-return (2019)
For every dollar spent, the return on investment is nearly US$ 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
.76.
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
.77.
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
.78.
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.
79.
Wikipedia. US military spending reduction after WWII. Wikipedia https://en.wikipedia.org/wiki/Demobilization_of_United_States_Armed_Forces_after_World_War_II (2020)
Peaking at over $81 billion in 1945, the U.S. military budget plummeted to approximately $13 billion by 1948, representing an 84% decrease. The number of personnel was reduced almost 90%, from more than 12 million to about 1.5 million between mid-1945 and mid-1947. Defense spending exceeded 41 percent of GDP in 1945. After World War II, the US reduced military spending to 7.2 percent of GDP by 1948. Defense spending doubled from the 1948 low to 15 percent at the height of the Korean War in 1953. Additional sources: https://en.wikipedia.org/wiki/Demobilization_of_United_States_Armed_Forces_after_World_War_II | https://www.americanprogress.org/article/a-historical-perspective-on-military-budgets/ | https://www.stlouisfed.org/on-the-economy/2020/february/war-highest-military-spending-measured | https://www.usgovernmentspending.com/defense_spending_history
.80.
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
.81.
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
.82.
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/
.83.
Oren Cass, M. I. 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
.84.
al., N. E. Á. et. 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
.85.
Museum, N. S. 11. M. &. 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.
86.
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
.87.
Fund, I. M. 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
.88.
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
.89.
CSIS. Smallpox eradication ROI. CSIS https://www.csis.org/analysis/smallpox-eradication-model-global-cooperation.
90.
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
.91.
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
.92.
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/
.93.
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
.94.
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/
.95.
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
.96.
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
.97.
Institute, C. 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
.98.
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
.99.
One, P. 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
.100.
Bureau, U. C. 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
.101.
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/
.102.
Diseases, G. 2019. & Collaborators, I. 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.
103.
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
.104.
Oncology, J. 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
.105.
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
.106.
Care, D. 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
.107.
CBO. The 2024 Long-Term Budget Outlook. https://www.cbo.gov/publication/60039 (2024).
108.
World Bank, B. of E. A. 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
.109.
Group, E. W. 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/
.110.
Alliance, D. P. 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.
111.
Fund, I. M. 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.
112.
Papanicolas, I. 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
.113.
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
.114.
Lab, Y. B. 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.
115.
Foundation, T. 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.
116.
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
.117.
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
.118.
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
.119.
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
.120.
Bureau, U. C. 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
.121.
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
.122.
Bureau, U. C. 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
.123.
Senate, U. S. 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
.124.
Commission, F. E. 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/
.125.
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/
.126.
Hutchinson & 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.
127.
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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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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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Japan’s zoning system operates with 12 national zones that permit multifamily housing and mixed-use development even in strict zones. Development follows ’as-of-right’ approach without discretionary review. Unlike the US where homes are investments and 89,000 municipalities create restrictive zoning, Japanese homes depreciate completely within 22 years and national framework limits local restrictiveness. Result: Tokyo ranks among the most affordable developed-world cities despite being a megacity of 14 million.
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