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Dylan Marando: Hope in Health Care: Early disease detection is saving lives

Commentary

“No. I cannot expect you to believe it. Take it as a lie—or a prophecy. Say I dreamed it in the workshop… Treat my assertion of its truth as a mere stroke of art to enhance its interest. And taking it as a story, what do you think of it?”

Such is the plea of H.G. Wells’ protagonist in the classic novella The Time Machine—a still gripping imagining of our ability to look around the chronological corner, perhaps to avoid its perils. The Time Traveller, as the speaker is known, acknowledges the strangeness of his claim to have seen the future. He knows the technology which enabled his prophecy is implausible. Yet, he is determined to convince his dinner guests, including the skeptical Medical Man, that we can know what lies ahead, and we must act to prepare for it. He presents his guests with some “withered white flowers” as evidence of his journey. They don’t heed the call.

But now, in an irony worthy of Wells, it is the Medical Man (or medical community) claiming to be prophetic. And, this time, it is the medical community that is desperately displaying evidence in the hopes of convincing others to act. We, and policymakers in particular, should heed the call.

Over the last several years—COVID-19 aside— the medical community in Canada has become steadily and deservedly more confident in its ability to forecast each of our medical futures. Part big data, part deep learning, part analytical insights, and part old-fashioned technological discovery, medicine is in the midst of a great decade of diagnostics, in which preventative health care is top-of-mind and the international community is rallying around the goal of improved access to screening technologies.

The quality of medical tests (be it in the lab, the radiology unit, or in the community), and the interpretive abilities of health-care providers, are not just better than it was a few years ago (as is the natural course of things) but dramatically better. And, in light of this, norms around disease screening are being legitimately questioned; perhaps most topically, in Canada, in the domain of breast cancer screening, and due to recent research from the University of Ottawa.

Admittedly, the notion that early detection improves clinical outcomes is not novel and has always had an intuitive appeal. In the current medical moment, however, evidence encouraging public policies that do more to enable predictive health care—including, but not limited to, smarter screening programs— is so undeniable as to inspire the growth of social movements. Providers, patients, and policymakers can’t turn away from the fact that someone diagnosed with Stage 1 lung cancer has a five-year survival rate of more than 60 percent, whereas a patient diagnosed at Stage 3 has a survival rate of roughly 15 percent. For breast cancer and ten-year survival rates, those figures are 96 percent and 53 percent, respectively. The cost-effectiveness of early breast cancer screening is potentially five times greater than the cost-effectiveness of screening in older patients. Put simply, seeing the future saves lives. And public policies that determine the timing and venue of diagnostic services matter immensely.

To which, the skeptical policymaker might ask: but can we actually do it? Can we actually, credibly predict what ailment you or I might have, and what tailored treatment you or I might need?

From a geneticist, the answer would be a resounding: yes! In oncology, for example, where genomic-based screening is becoming both sharper and more normalized, a health-care provider can gain insights into an asymptomatic patient’s risk of cancer that would have been unimaginable only a few years ago. To cite one of the latest Canadian-based breakthroughs, researchers at the University of British Columbia have developed a new hereditary cancer test that allows us to determine which parent might have generated a cancer-predisposing gene variant. This permits a much more focused approach to additional familial testing, as well as associated preventative health efforts.

Similarly, at the University of Alberta, a set of scientific trailblazers uncovered a new genetic marker linked to an increased risk of breast cancer. This discovery could enable earlier detection, contribute to a more tailored therapy regime, and shape the health-care community’s capacity to build population-based genomic screening models. In other words, we’re now seeing disease before it happens, at scale.

Shifting our gaze to the universe of instrumentation, innovations like the Nobel Prize-winning cryo-electron microscopy are also reason to be optimistic about our power to proactively manage disease states. While not oriented toward individual patient diagnosis in the same way genetic-based screening can be, cryo-EM technology (which has found an international centre of excellence in McGill University) literally freezes time (and proteins) so we may observe a new level of detail about the behaviour of biomolecules, generating a new level of understanding about therapies. And akin to the varied riches that now feature in the genetic research space, cryo-EM is just one of many new instruments that are revolutionizing what it means to “see” disease—both at the level of the individual patient and at more abstract levels of analysis. Add to that list: deep light imagingthree-dimensional MRI; and deep-tissue imaging.

And if foundational research and technological progress aren’t enough to convince you that the Time Traveller’s dream has started to come to life, look to select enlightened public policies as a further proof point of our predictive powers. Returning to the cases of lung cancer and breast cancer, we can be encouraged by the U.K.’s roll-out of mobile lung cancer screening, or (closer to home) Nova Scotia’s now longstanding leadership in mobile mammography. In the U.K., the push to scale lung checks through “NHS lung trucks” resulted in more than three-quarters of the cancers caught by the initiative being detected at stage one or two (which is startling, considering that less than a third of lung cancers in the U.K. are normally caught at those earlier stages).

Having said this, it would be a stretch to argue that the quantum and quality of public policies embracing predictive health-care interventions, such as better screening, are in any way equaling the insights and outputs of the medical community’s work in that space. While it seems fair to say that the concept of time in medicine has been bent—in the best possible way—, it’s less clear that providers and patients are being given the resources to act on such a warping of time. Whereas words like “symptom” or “remedy” might be replaced by phrases like “disposition” or “high-risk-population” at medical conferences, the health-care nomenclature of legislative buildings can be staler. As alluded to above, the pandemic might have shaken the confidence of some policymakers in the power of health forecasting.

But, as health systems are consistently being reminded, it’s critical to guard against recency bias and thus not forget about the range, depth, and breathtaking acceleration of medical advances that immediately preceded, paralleled, or quickly followed the lowest moments of COVID-19. Policymakers need to lean on the evidence and thus resist the tendency to apply old norms, old frameworks, and old practices (even those that are just a few years old) to new data, new analytics, new instruments, new capacities of providers, and new expectations of patients.

Alas, recency bias can be especially sticky in public policy ecosystems—given the democratically justifiable influence of political cycles. And public policy stickiness can be especially gummy in the health-care sector, given the existential risks involved in health policy decision-making. But it is precisely because of these stakes that policymakers can’t afford to ignore advances in medical science and the relationship between those advances and public policy program parameters. Likewise, as patients, we are compelled to relentlessly question the ability of our policy systems to keep up with the realities of our science.

Breast cancer awareness month has just concluded, and we must be tirelessly praising medical progress. And we must hope that, for those of us long energized by the future-oriented visions of Wells, our time has finally come.

‘Getting the cream to rise’: George F. Will on what liberalism gets right

Commentary

On Friday, November 3rd, The Munk Debates held its 29th main stage debate, presenting the following motion: “Be it Resolved, liberalism gets the big questions right.”

Free trade, capitalism, and individual rights have remained foundational to liberalism, but more recent criticisms blame liberalism for problems such as growing inequality and political polarization. Has liberalism become a roadblock in the path of progress? Is a new guiding ideology needed to replace it?

George F. Will, foreign and domestic affairs columnist for The Washington Post, argued for the Pro side of the motion. Here is his opening statement from the debates.

Liberalism gets the big questions right to keep the peace. That’s the fundamental problem in politics—social peace.

Liberalism gets the big question right by leaving many big questions out of politics. Is there a God? How should we worship? What is virtue? How should we promote it? Should we have false consciousness purged and true consciousness inculcated? Liberalism doesn’t do that. Liberalism recognizes that the great problem of politics is that human beings are opinionated and egotistical. They like their opinions, and they have different opinions, yet they have to live together in peace.

Liberalism is often faulted as pedestrian and boring. I prefer to say it has heroic modesty. It does not presume to tell people how to find meaning of their lives in politics. Genuflecting at the altar of politics is illiberal and produces illiberalism. My debate partner, Jacob, is a devout Catholic. I describe myself as an amiable, low-voltage atheist. It doesn’t matter. We could live together in a liberal society because the government is neutral about such things.

Some people in politics say, “Let’s envision the best and pursue it.” Prudent classic liberals say, “Let’s define the worst and avoid it.” And Lord knows we’ve had enough of those. Classic liberalism, let’s define it with economy. It believes there is a settled human nature, and that natural rights are derived from that. Natural rights are rights that history teaches us are essential to the flourishing of people with our nature.

All illiberal politics in the last two centuries have begun by saying that there is no fixed human nature, that human beings are merely products of the culture they find themselves raised in, that malleability is the most important feature of human beings, and therefore, firm, hard-driving, coercive politics is justified to produce the proper consciousness in people. False consciousness must be gone, people must be conditioned. Speech must be limited because it does harm by giving people the wrong consciousness. The vocabulary of liberalism cannot cope with that. And when you go down that path, you wind up either with the Khmer Rouge in Cambodia—or on a typical American campus today.

Another way that liberalism keeps the peace—and remember, peace is always the fundamental problem—is by having markets allocate most opportunity and wealth. The alternative is political power will allocate opportunity and wealth, and that way lies bitterness. That way lies an unhealthy high stakes of politics. Let impersonal market forces do these things, and you will not have the bitterness that comes from the ever-increasing high stakes of politics that determine who prospers and who does not.

Now, it is said that liberalism produces inequality. Indeed it does. If you say you are for liberty, you are for inequality, because people have different attitudes and aptitudes. Some people want to teach kindergarten, some people want to run hedge funds. Bless them all. But the rewards are going to be different, monetary and otherwise.

A classic liberal society says we want, above all, meritocracy. Careers open to talents. Obviously, any society is going to be governed by elites. The question in any mature society is not whether elites shall rule, but which elites shall rule. And the challenge of democracy is to get consent to be governed by worthy elites.

When I was young and the world was young, in the late ’60s, I taught at the University of Toronto, where a particular luminary at the time was C.B. Macpherson, a very fine political philosopher, whose subject of main interest was possessive individualism, which he did not much care for. I think possessive individualism is excellent. It is the direct descendant of Locke’s teaching from which most of our liberalism descends.

Possession is important because possessions give us a zone of sovereignty that is not dependent on state power. Possessive individualism matters, because when you step away from individualism, when you step away from the individual as the fundamental social unit, you find yourself where we are today with tribalism, with people defining their identities by their group memberships and a zero-sum scramble for preferences as one group throws elbows against another.

The fact is that liberalism produces, as no other political philosophy can, an open society, a churning society. Yes, it’s disorderly. That’s part of the fun. But as the great American poet Robert Frost said, “I do not want to live in a homogenized society. I want the cream to rise.” Classic liberalism is a recipe for getting the cream to rise.