A Plague from Within¹

by Ian Magrath

.....in the midst of a scourge, there is more to admire in the actions of men than to despise.....

—Albert Camus, La Peste

Source: The Nature Yearbook of Science and Technology, 2001 Figure 1

A Dickensian Antiphony

In the course of the last century, humanity has sunk to its greatest depths and risen, by some measures, to its greatest heights. The world has been consumed by two world wars that resulted in 50 million civilian deaths in Europe and the Soviet Union alone. Unfortunately, war appears to be a perennial affliction of the human race. More than 60 major armed conflicts have begun since 1945, approximately 50 of which continue to the present day in some shape or form. Violence not infrequently reaches the level of mass slaughter or even genocide—more than 800,000 people were killed in Rwanda, for example, in 1994. The majority of these conflicts are in developing countries in which the deaths and serious injuries often have a greater and more lasting impact on societal structure than they would in societies with more advanced infrastructure. Moreover, they create millions of refugees, many of whom flee to countries barely able to provide for their own populations, such that death rates from starvation and disease among the refugees are high. The recent attacks in the USA caused the deaths of more than 5,000 civilians who came from 80 countries. Future terrorist acts as well as counter-terrorist measures will inevitably result in the deaths of even more innocent people. The INCTR extends its sincerest condolences to the families, friends and fellow countrymen of all of the innocent victims of the various heinous acts that have littered recent history and which will, unfortunately, almost certainly continue into the foreseeable future.

Yet while host to internecine struggles of cataclysmic proportion, the last century has also witnessed unprecedented advances in science and technology, without which, ironically, neither the recent attacks in the USA nor the almost instantaneous transmission of the devastating images of death and destruction to every corner of the globe (a result clearly desired by the perpetrators) would have been possible. We live in an era in which the secrets of quarks and bosons, the elementary particles of matter, are being unraveled, space probes are sent to the furthest reaches of the solar system, and more than 90% of the human genome has been sequenced. Many of us are fortunate enough to be able to enjoy, first-hand, the cultures of many other countries and peoples, as well as the artifacts, literature and music of other ages. More than 500 million people now have immediate access to enormous quantities of information through the Internet.

A Faustian Dilemma

Paradoxically, despite the enormous strides made in the fields of science and technology, ignorance and poverty still engulf a large proportion of the human race, and diseases, old and new, continue to ravage populations. Average life expectancy has greatly improved, but socioeconomic inequity is increasing. Today, more than one billion people drink unsafe water and 2.4 billion are without adequate sanitation. Approximately 3.4 million people, mostly children, die each year of water-related diseases, over a million from malaria alone. In 1999, there were 5.4 million new cases of AIDS (4 million of whom were living in sub-Saharan Africa) and 8.4 million new cases of tuberculosis, while in the year 2000 there were 10 million new cases of cancer. The sheer scale of the human misery caused by these diseases, which is predicted to increase dramatically with time (cancer cases will reach an estimated 20 million by 2020) is incomprehensible. One may, I hope, be forgiven for asking whether this is indeed a paradox, or simply a consequence of human nature and the laws of mathematics. But whatever its cause, the profound Dickensian contrasts of the twentieth century confront us with a major challenge for the twenty-first century. How can we bring the benefits of science and technology to the huge fraction of the world's population that presently has little or no access to them? And at the same time, how can we avoid the misuse of technology—in the words of Faust, the false path arising from the fact that so much poison is hidden in the cure?

E Pluribus Unum

The recent terrorist acts in the USA have galvanized the world into an unprecedented cooperation to deal with the threat of future attacks, for aggression of such magnitude and consequence against the richest, most powerful, most influential and most visible country on earth unequivocally demonstrates universal vulnerability and has created huge social, political and economic reverberations globally. To control terrorism—the perpetrators of which can hide amidst the general population, are succored by multiple resources wittingly or unwittingly provided, move easily from one country to another, and can turn the accouterments of everyday life into weapons against innocent people—broadly-based global cooperation is essential. We can but hope that September 11 will become not only a day of remembrance for the victims of terrorism, but also a day on which to celebrate the beginning of a new world order—a day that catalyzed the nations of the earth to unite to a previously unprecedented degree in combating not only terrorism, but all common enemies. If so, the deaths and suffering will not have been in vain.

It is only in the twentieth century that wars on a truly global scale have erupted, and as a reaction to their previously unimaginable horrors we have witnessed the emergence of international organizations whose members are nation states, such as the United Nations (including the World Health Organization and the International Court of Justice), the World Trade Organization and the World Bank. While there is perennial debate about the efficiency and success of such organizations, the fact of their existence, combined with such instruments as the Universal Declaration of Human Rights (see panel below), signifies that the human race is moving into an era in which international interactions are increasingly subject to the rule of law and independent arbitration rather than to the ancient formula of "might is right." There is, of course, a considerable distance to travel along this path pitted with land mines, and many nations will be wary of subjecting their present freedom of action to international consensus, particularly when such consensus must be reached by countries with broadly different cultures, economies, interests and sensibilities.

But whereas political commonality may be difficult or impossible to reach, there is a surprising degree of agreement on universal human rights. Perhaps too, there can be consensus on universal threats, for there can be no more potent a unifying force. International terrorism, the enhanced power of which in this technological era has been so starkly demonstrated, is on center stage at the moment, but other, more endemic problems such as ignorance, poverty and disease affect vastly greater numbers of people and also carry major and more sustained socio-political consequences. Concerted action is surely the most effective means of dealing with these problems, and ought also to be particularly achievable in the context of disease, since the latter is less susceptible (although not immune) to differing political perspectives. The eradication of smallpox stands as an example of successful international action of this kind. Moreover, improving the lives of people is likely to be a potent means of increasing national and international security.

In an era in which tools capable of changing our biological nature have emerged (to be greeted, quite naturally, with clamorous debate), alongside the ability to annihilate the human race, perhaps the time has come to seek to match these technical marvels with political and organizational structures of equivalent virtuosity. Probing the mysteries of fundamental particles or the human genome may be likened to pushing the accelerator of progress, but by the same token, the interwoven blights of ignorance, poverty and disease are huge burdens which act as brakes, both by reducing the intellectual potential of the human race and, perhaps worse, by predisposing populations to crime, social unrest, political instability and ultimately, armed conflict. Poverty and ignorance provide a breeding ground, if not for the architects of terror, at least for those susceptible to its propaganda.

Extracts from the Universal Declaration of Human Rights Article 25 (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services. Article 26 (1) Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit. (2) Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace. Article 27 (1) Everyone has the right freely to participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.

Minimizing Harm

The versions of terrorism are many and varied. Consequently, effective control is dependent upon the gathering of "intelligence" about the locations of terrorists, their means of support and the acts they plan to commit. The eradication of terrorism, based on such intelligence, must be carried out with a minimum of harm to innocent people—whether physical or at the level of societal freedoms. Research into the origins of terrorism is also essential if we are to prevent it. This will entail much soul-searching and greater attention to the long-term results of political or military actions.

Strong parallels exist with disease control, perhaps because terrorism is, in effect, a plague from within, a cancer that attacks the innocent and unsuspecting. Cancer, like terrorism, has definable causes which will need to be identified through research for intervention to be successful. While a major element of prevention must be socio-political, immediate action is necessary to minimize the suffering of present victims. In order for appropriate authorities or donors to commit the needed resources to disease control, scientists and physicians must be responsible for providing evidence (intelligence?) concerning cancer patterns in various world regions, for the causes of individual cancers, and for the effectiveness of preventive or therapeutic measures. Sometimes, disease prevention can be accomplished by a simple act. Hand washing with soap and water can reduce the incidence of diarrhea by 35%, and smoking cessation dramatically reduces the mortality from several cancers and many other diseases. Of course, modifying human behavior, particularly that associated with a significant psychological, political or economic benefit, is never easy. Reducing smoking rates, for example, is not simply a question of dealing with addiction to nicotine, but also involves addressing the competing influences of different sectors of society, some of which stand to profit enormously from encouraging the smoking habit. Consequently, in spite of knowledge of tobacco's harmful effects, Richard Peto has estimated that there were 71 million tobacco-related deaths between 1930 and 1999 in industrial nations alone, and the World Health Organization estimates that there are presently 3 million deaths a year worldwide from tobacco, almost a third of which occur in developing countries.

Where prevention fails, it is essential to confirm the diagnosis of cancer. Missing the diagnosis may have fatal consequences, and an incorrect diagnosis may lead to unnecessary psychological anxiety as well as to time-consuming, expensive and potentially risky treatment. Treatment should be no more than is necessary (proportionate?), and adjusting treatment to risk is a difficult task that entails identifying the locations of cancer throughout the body. The collections of cancer "cells" (a word recently co-opted to refer also to terrorist groups), are particularly difficult to eliminate when scattered throughout the body since (collateral?) damage to normal tissues must be kept to a minimum, although it is difficult or impossible to avoid altogether.

An Equal Music

Fighting cancer, like terrorism, is not a single process and requires application of a broad range of approaches to its prevention and treatment. These, in turn, must be managed by highly trained, dedicated teams of professionals—underpinned, of course, by the political will to commit the required resources. Because of its cost, it attracts little attention as a health problem in the poorest, heavily indebted nations, which must sometimes focus all of their available resources on providing clean water and helping their infants to survive beyond the age of five. Similarly, international organizations, for many reasons, tend to focus primarily on these grass roots problems even though many developing countries have undergone significant epidemiological transitions such that mortality rates from chronic diseases, including cancer, are rapidly rising and represent a health challenge of ever increasing importance. But research in fundamental physics, cosmology and sophisticated biotechnology is conducted in nations whose average wealth is high, but in which poverty has yet to be eliminated. Whilst priorities in government spending will always be hotly contested, some of this research is conducted by non-governmental organizations, and in any event, the greater good is probably better served by including significant expenditure on fundamental research whilst simultaneously addressing the alleviation of poverty and ignorance—indeed, the former may, sooner or later, have a significant impact on the latter.

By the same token, given that cancer is a global problem, all nations need to address it at some level, although there must, of necessity, also be quantitative and qualitative differences in national emphasis. Enhanced international cooperation is likely to have a synergistic effect on efforts to control cancer although, as with other global coalitions, individual countries will contribute in different ways or to different degrees whether with respect to the provision of financial support, experts, or simply helping to take advantage of opportunities to better understand one or more aspects of cancer. At present, a tiny fraction of global research, including medical research, takes place outside North America, Europe, Japan and Australasia (Figure 1), yet the developing countries provide an immensely rich source of potential knowledge about cancer, as well as numerous, largely untapped opportunities for the conduct of research into its prevention and treatment—research that would help both the local populations as well as people everywhere. These opportunities are currently being largely overlooked, partly because of the mal-distribution of global resources, but also because many western researchers are not aware of the possibilities that exist for effective collaboration. Changing this situation should be given a much higher priority.

In 1971, Richard Nixon, then President of the United States of America, announced a war on cancer. The consequent boost in resources has been of tremendous benefit to understanding and controlling cancer, but almost all of these benefits have been reaped by the rich countries. Cancer, like terrorism, is a scourge that merits exceptional action on the part of the international community. In this United Nations Year of Dialogue Among Civilizations, might not cancer be elevated, along with other common ills, to the rank of a global problem that, like terrorism, requires global action? And should not developing countries, home to the major part of human suffering, be involved more fully in the struggle against it?