Figure 1. The number in parenthesis after each country is its rank order in the United Nations Development Programme Human Development Index.

Grand strategy is a term most often used to refer to the collection of political and military means that nations employ to ensure their security. Human group strategies (originally tribal or dynastic, and more recently, national), largely reflect the underlying biological imperatives that apply to a broad range of social mammals and are part of the grand biological strategy of selecting specific gene pools (i.e., gene variants or alleles) for survival through the process of Darwinian competition. The predominantly male imperative to dominate other members of the same hierarchically structured group is inextricably intertwined with reproductive advantage, while the territorial imperative, or drive to control essential energy resources (originally exclusively food), may be seen as a survival strategy which ensures maximal use of geographically distributed resources, while at the same time, buttressing individual competition, the engine of evolution, with intergroup competition. This second element, again, a largely male-dominated affair, includes the opportunistic elimination or subjugation of potential competitors, and the additional option of gene dispersion, furthering the chance of the survival of particular gene pools. It differs from individual competition within a group in one important respect — there is less compunction with respect to total annihilation of competitors (genocide), since not only are such competitors genetically more distant (or rather, were, particularly in the pre-historic era), but their extermination has no direct impact on the social structure of the victorious group and may have a survival advantage — the acquisition of additional energy sources through territorial extension. In agricultural and urban societies, the subjugation of at least a fraction of the competitors as slaves could also be beneficial — as a supplementary or even major workforce, or as a commodity for barter. While intergroup cooperation, for example, through the exchange of goods, may prevail for lengthy periods, competition tends to be more likely when resources are sparse (hence more conflicts occur today in developing countries) and is often, therefore, associated with migration and colonization. These characteristics of group competition, which attest to the biological origins of human warfare, are well described in ancient texts, including the Hebrew bible (e.g., Deuteronomy 7,16-23; 20,10-18). Such records also illustrate the process whereby compassion and a sense of justice, essential emotional elements in a social animal capable of deductive thought, must be suppressed, in the context of intergroup competition, through a process of rationalization. Human political history consists largely of a series of variations on these themes.

The biological equivalent of a grand strategy for human evolution, i.e., the development of an unprecedented capacity for imagination, and its soul mate curiosity, in conjunction with the anatomical and neurophysiological requirements for sophisticated tool-making, led within a mere (in evolutionary terms) million years or so of the emergence of Homo sapiens to a remarkable ability, for a single species, to adapt to a broad range of terrestrial environments. The process of adaptation and continued cultural evolution doubtless spurred on by the innate competitive drive and profited from the pooling of intellectual resources within and between (if sometimes involuntarily) groups. Unfortunately, the remarkable synergistic combination of the human brain, hand, and upright gait also led to the catastrophic World Wars of the 20th century, and since then, to the brink of extinction. It would seem that cultural evolution, however deeply rooted in biology, has escaped its genetic constraints such that the Darwinian doctrine of “survival of the fittest” has taken on a Lamarckian hue. “Fitness” is no longer strictly associated with genetic modulation, but can be directly acquired by one generation or group from another, thus permitting a dramatic acceleration in the pace of change, increasing the likelihood of a mismatch between intellect (wisdom) and power, and potentially inverting the basic Darwinian thesis, all of which could lead to consequences at least as great as the mass extinctions of the late Cretaceous period.

The disastrous beginning to the 20th century may be seen as a result of the clash of the grand strategies of Germany, France, Great Britain and Russia in their competition for mastery of Europe — and a portent of potential future catastrophes. The massive scale of destruction illustrates the dangers inherent in strategies predicated upon gaining a competitive group advantage in the context of advanced capabilities in science and technology. But although the nuclear weapons, long-range missiles and other nefarious devices which have replaced the stone axes of a few thousand years ago, are unlikely to lead to the salvation of a genetically defined human population, cultural evolution, including both technological and methodological progress can, and indeed, has, benefitted the entire human race. Continued survival will depend upon the ability of leaders, great and small, not to suppress their biologically programmed imperatives, which is probably an impossible task, but to redefine the “group” to which they belong as all of humanity, and to redirect the creative resources of the species towards overcoming common enemies, such as disease, rather than perceived competitors. Unlikely, though such a shift in perspective may seem, particularly since many continue to benefit from the present long standing, instinct-driven and culturally reinforced world order, there are at least some signs of a movement in this direction. For example, the dramatically increased access and continued development of air travel and telecommunications in the last few decades, despite the “digital divide”that exists between rich and poor (Figure 1), has exposed an ever-increasing fraction of the world’s population to other cultures and ideas, thereby greatly increasing peaceful cross-cultural interactions, particularly in the arts and sciences, and to a lesser extent with respect to political and religious systems. This has made possible, for the first time in history, the conception of a global community founded on cooperation rather than competition. Indeed, since the biological process of natural selection has, at least for more advanced societies, been essentially abrogated by scientific progress, the grand geopolitical strategies that have emerged in the last few centuries, may, from this viewpoint, be seen as grotesque cultural parodies of the underlying biological imperatives.

It is possible to imagine a world in which the combined intellectual resources of humanity were directed exclusively to the common good rather than to the dominion of one group over another. Is, however, such a world possible?

Increasingly, daily life is based on data and algorithms rather than mythology and conjecture. If the fruits of nature are to be harvested, however, without the dire consequences that resulted from Eve’s earlier attempt, we must follow Francis Bacon’s advice (see epigram). This includes developing a broader understanding of our own nature and how the process of rationalization, based until now on the association of ideas that gives rise to mythology, can be diverted through a process of scientific understanding to the advantage of all, rather than to the detriment of many. The moral neutrality of left brain logic, however, will require a healthy admixture of right brain compassion, mutual respect, and aesthetic appreciation — one might say, spiritual growth — if its benefits are to extend to all, including the most vulnerable and disadvantaged populations.

There is reason for optimism. In spite of the constant presence of violent conflict in the world, there is evidence that the cooperation essential to the functioning of individual social groups is slowly emerging from its tribal (dynastic), racial, and national contexts into a new, international, community. In reaction to the devastating wars of the last century, global strategies in fields such as the environment and health have been developed and have taken their place, not always with general approbation, alongside geopolitical strategies which, although remaining effectively national, are increasingly debated in international forums. In part, this is because the environment and health are finally being recognized as highly relevant to global security, and provide common goals at a time when the promotion of international cooperation to achieve international peace and security — the grounds for the establishment of a League of Nations after the Great War — have become even more urgent. In this respect, it is important to emphasize areas of agreement rather than disagreement and essential to ensure that science for peace and universal human benefit becomes the dominant grand strategy of the 21st century, providing hope of eventually reaching the 22nd.

A Grand Strategy for Cancer Control

Grand strategies entail deciding how to reach a predetermined goal, the goal, perhaps, rather than the strategy itself, determining whether or not the epithet “grand” is warranted. Ambitious goals will usually require the inclusion of multiple elements of varying importance in the overall strategic design. A major pillar of the geopolitical strategy of the British Government for several centuries, for example, was the building and maintenance of a preeminent navy. This permitted protection of the island nation, projection of its power to all parts of the world and the assurance that international trade via the major sea routes would be interrupted as little as possible. It also permitted the discovery of new sources of raw materials, new trading partners, and was a medium for scientific discovery — witness the voyages of Captain Cook to the South Pacific, in which more precise maps than ever before were made, advances in astronomy and physics, consequent upon the importance of the heavenly bodies to navigation, medical advances (e.g., overcoming scurvy) and, through Darwin’s travels to South America, the theory of natural selection. Ultimately, of course, this was a national strategy that was in constant collision with the strategies of other countries. Its implicit foundation, conscious or not, was that knowledge leads to power, and power to security. This, and its global scope resulted in universal benefits that could not have been foreseen. As a consequence of this and similar strategies of other nations, communications now occur at speeds of millions of bits per second rather than a few nautical miles per hour, such that knowledge itself can be projected — or received — from anywhere in the world to almost any other place, not excluding the most physically inaccessible African village. Clearly, a grand strategy for cancer control must also be global in scope.

Any Grand Strategy is ultimately based on the accumulation and effective use of knowledge.

Unfortunately, the gross disparities in the world ensure that the 85% of people who live in developing countries — countries, incidentally, which in the past have made fundamental contributions to a broad range of human endeavors, including science and mathematics — have, through the broad impact of socioeconomic privation, less opportunity to both benefit from and contribute to the continuous augmentation of the human knowledge base. A grand strategy for cancer control cannot exclude developing countries (which account for 60% of the world’s cancer), and must therefore have, as a central theme, improving both knowledge creation and access to knowledge throughout the world, for in the absence of knowledge (logos), chaos must reign. Such a grand strategy goes beyond cancer control, since it must underpin all aspects of the promotion of sustainable development. Indeed, cancer control cannot be separated from development, for not only will the latter contribute to improved cancer control, but improved cancer control, by virtue of the improvements in education and health facilities it will entail, and its impact on morbidity and premature mortality, will contribute to sustainable development.

It must be said that economic development does not always result in major benefits to the bulk of the population of a country (or, indeed, the world). Improvements in gross domestic product, for example, first benefit the more wealthy sectors of the community, and economic disparities may persist as countries become more affluent. At a global level, the President of the World Bank, in a recent speech, pointed out that in our present world of 6 billion people, a billion inhabitants control 80% of global GDP, whilst in excess of another billion live on less than a dollar a day. Affluent countries spend $56 billion a year on development assistance (0.22% of GDP, down from 0.5% in the early 1960s), $300 billion on agricultural subsidies and $600 billion on defense. Even poor countries spend $200 billion a year on defense - more than they spend on education or health. Yet today, only half of the children living in Africa will complete primary school and the average life span on this continent is decreasing. The fact that the majority of people in the world have poor or no access to education and health care, while in the affluent countries over-consumption is a major cause of ill-health, is surely indicative of a world that is out of balance (Figure 2). Asking why such inequities are allowed to persist — indeed, are often fostered — may provide some valuable insights into the nature of modern human society, while an examination of some of the strategies used in politically-inspired warfare may help to understand why the war against cancer is failing in the greater part of the world.

Figure 2. The number in parenthesis after each country is its rank order in the United Nations Development Programme Human Development Index.

Lessons from the Great War

The Great War had incalculable consequences for “civilization.” Both sides aimed for nothing less than total victory and this was the first “total” war in which entire populations, including men, women and children, were engaged in the conflict. Societal “norms” were overturned, often for the better. Women stepped into the gaps left in the traditional male workplaces as their fathers, brothers and sons were drafted to the front lines and in doing so, took a giant step forward with respect to their place in society. They produced food and weapons, participated in the hostilities as auxiliaries, and cared for the wounded. The need for maximal efficiency led to better conditions and increased wages of the non-combatant work force. And while the balance of power seemed to hover over the mud and trenches of the roughly 400-mile-long Western Front, air and sea warfare evolved rapidly as the British established a naval blockade in an attempt to starve Germany into submission. In the Great War, bombers, aircraft carriers, submarines, tanks and long range guns — the precursors of missiles — were all invented, as was poison gas, the first of the weapons of mass destruction. It seems there is no limit to the ingenuity and energy of man in attempting to dominate his fellow. No less ingenuity and effort should be demanded in mobilizing the necessary forces and creating the necessary tools to conquer common enemies. In the Great War, governments took almost total control of their populations (and of the provision of news and information) and entire national workforces were directed, in a highly coordinated way, towards the war effort. While only a proportion of the population can focus all of its energies on fighting cancer, the professional capacity to control cancer is grossly insufficient in developing countries, and must be increased. In addition, every man, woman and child must, to a degree, be engaged in the struggle, for each is a potential victim of the disease. Women, in particular, are a greatly under-used human resource throughout much of the world where traditions, limited mobility, lack of education and access to information, and a limited voice in society marginalize this half of the population. Similarly, poor working conditions, low wages, limited protection against emergencies and lack of institutions coordinating human behavior, are all aspects of life in developing countries which greatly limit the value of human capital and hinder development. The carnage of the Great War led to the loss of mercy, truth and love — at least on the battle fronts. One cannot help but wonder whether such qualities are similarly suppressed with respect to developing countries, for how else can the misery that so many endure be allowed to continue in the face of such affluence elsewhere? In the war against cancer, these qualities must be nurtured and transformed into powerful inspirational forces that help to create essential resources, and ensure that cancer patients, unlike the soldiers in the trenches, retain their dignity no matter what the outcome of their own particular battle.

In fighting a total war on cancer, three elements of the population need be considered: the general public, the non-specialist health care workers (including traditional practitioners) and experts who deal with cancer in one way or another. The public need to know about risk factors that can be avoided, and the early signs of cancer that can be detected and reacted to immediately. The non-specialist primary health care worker must know enough about cancer to recommend, or carry out screening tests in target populations, to recognize the early signs of cancer and to seek appropriate specialist help when necessary. Policy makers and public health specialists need to encourage healthier lifestyles in the population at large, through the provision of information and enactment of legislation. Governments and regional authorities also need to address the issue of the equitable distribution of the cancer services required to serve the needs of the population. Cancer specialists as a group must be well informed and able to effectively apply present knowledge while also striving to develop new and better weapons and strategies against cancer. Cancer control must always include disease-specific strategies, and approaches to prevention and treatment will also need to be molded to fit different socioeconomic and cultural circumstances. Finally, a grand strategy for cancer control cannot be simply international, it must be supranational, that is, it must encourage global participation and global cooperation at all levels, both in the search for new knowledge and in the wider application of existing knowledge. For only when the barriers between peoples disappear can there be a united front against a common enemy.

Elements of a Grand Strategy to Control Cancer One. Cancer afflicts all of humanity and all of humanity must therefore be engaged, in one way or another, in combating it. Two. All sectors of the professional community involved with cancer control — governments and government agencies, non-governmental organizations, academic institutions, private corporations and professional societies — must work closely together. Three. Successful cooperation requires good leadership and mutual benefits. Four. Cancer must be controlled through the use of scientific evidence relating to its causes, prevention, diagnosis and treatment (whether with curative or palliative intent) and clinical research should be closely tied to the provision of cancer services. Five. The quantity and quality of research into cancer causation and treatment must be increased, include a broad range of populations and environments, and be conducted according to international ethical standards by teams of professionals, where necessary, organized into cooperative groups. Six. Education must be a primary component of all efforts to control cancer — education of the general public, the non-specialist health professional, the specialist health professional, governments, and other policy makers (such as professional organizations) and those responsible for implementing policy. Seven. Capacity for cancer control must be matched to the needs of the population. Eight. Cancer control strategies must include disease-specific elements and be adjusted, where necessary, to serve the needs of specific populations. Nine. The most effective techniques, technologies and products possible should be used to control cancer throughout the world, but these approaches must be cost-effective. Ten. Health insurance should be universal (through means-adjusted premiums), cover prevention as well as treatment, and provide funding for immediatly relevant cancer research.

Part 2 - Meeting the Challenges - will follow in the next newsletter.