The Community and Cancer

Part 2. Civil Society

by Ian Magrath

....kings and persons of sovereign authority, because of their independency, are in continual jealousies, and in the state and posture of gladiators, having their weapons pointing, and their eyes fixed on one another. Thomas Hobbes in The Leviathon

Ruins of the Forum, the seat of political, religious, commercial and judicial activities in ancient Rome.

Parasites (paraseitos), in ancient Greek theater, were men who arrived uninvited to dine at the table of a wealthy family. In return for food (seitos) they amused their hosts with stories and anecdotes, even subjecting themselves to ridicule and abuse in the hope of winning a permanent attachment to the family. The Roman plays known as Fabula Palliata (pallium: cloak - the origin of the word “palliative”) were derived from Greek theater, but the equivalent character to the paraseitos in Roman theater was the cliens (a vassal or dependent) who differed from the paraseitos in that his presence was dependent upon an invitation. The invitation, in fact, was what really mattered, since the ultimate goal of the client was self-aggrandizement, and in the strict hierarchical structure of Roman society, to be invited to dinner by a member of the elite was a mark of recognition. Patronage of this kind was an important element of Roman society. Poets, artists, politicians and a variety of other clients were generally beholden to a patron and accompanied him to the forum - the seat of political, religious, commercial and judicial activities in ancient Rome. Clients, of course, were subject to the whims of their patrons, a relationship that tended to induce sycophancy. Independence of mind, although not unknown, was fraught with hazard.

Entertainers willing to “sing for their supper” appear to have been ubiquitous in former times. Fools appear in the courts of kings and noblemen in medieval and renaissance Europe, China, India, Japan, Russia and Africa - as did groups of comedians, actors and other entertainers, many of whom owed their livelihoods to their patrons. The foolery of court jesters, however, often provided more than mere entertainment. Since they posed no threat to the monarch’s power or self-respect they were uniquely able, through parody, burlesque and even mockery, to criticize his policies and actions. In ancient Greece and Rome stage acting and Fools coexisted; elsewhere it was the rise of the theater that led to the decline of the court jester. From that point forward, commentaries on the follies of kings and governments had a public face, soon to be rivaled by the rise, where permitted, of independent magazines and newspapers. These elements of society, like the Roman clients, are peripheral to the main societal structures, although they may still have a significant effect on decision makers by virtue of their role as societal mirrors. Unfortunately, also like the Roman clients, they are dependent upon patronage, which can affect their candor. Cartoonists and comedians, in contrast, can use the same powerful tools of the Fools of yesteryear to devastating effect, their humor serving now, as then, as a protective pallium.

Tricksters

Jesters have existed since long before the emergence of cities and Kings. Many African and American tribes had their clowns, often dwarfs, for the jester is a mythological archetype who appears in one form or another in essentially all mythologies, being frequently referred to as the Trickster. A wise fool, the trickster points to the flaws in human societies, deflates the pedant, questions constantly and urges us not to accept things blindly. He (or she) is of particular importance when new ways of thinking, i.e., change from the status quo is required, helping us to cross the boundary from one state or set of ideas to another. In this guise, the trickster blends imperceptibly into the magician (magi) or alchemist, whose concern is life-transformation. Tricksters also merge with heroes - the North American trickster, Coyote, for example, like the Greek hero, Prometheus, stole fire from the Gods. From life saving hero, it is a small step to a savior god. Clearly, the trickster, in all his guises (tricksters can change form or sex, passing easily from animal to animal to human) plays a critically important role in human society. Jung characterized the trickster as "a collective shadow figure, a summation of all the inferior traits of character in individuals," but he is surely more than this, reaching back, as he does, to our prehistoric psyche where he both represented the unpredictability of life and offered pointers as to how to live with this heavy burden. As such he is a precursor to many of the more well developed mythological and religious figures that later emerge on the tapestry of human cultural evolution. Perhaps he is the archetype of archetypes, capable, in parallel to life itself, of transmutation into a variety of forms that occupy a correspondingly broad range of psychological niches in many different cultures. And perhaps he still has much to teach us.

Leucochloridium Paradoxum

Remarkably, biological systems involving parasites include maneuvers that recall the psychological games of a trickster at points of transition. Ectoparasites such as fleas and lice, are able to simply move from one host to another, but internal parasites must rely on the behavior of the infected individual to make the crossing. The passage from an “intermediate” host, the site of larval multiplication, to the “definitive” host, which harbors the adult, can be particularly tricky. Leucochloridium paradoxum, a trematode flatworm that lives in the intestines of birds provides an illustrative example. Leucochloridium’s intermediate host is a snail of the genus Succinea, which becomes infested through eating the eggs of the parasite, present in bird droppings. The eggs hatch and the larval worms (miracidia) feast on the snail’s flesh - for the most part with only minor impediment to its daily affairs. Eventually the miracidia develop into sporocysts, which invade the snail’s eye stalks, causing them to become swollen and brightly colored. The consequent diminished ability to perceive light results in the snail wandering from the shadowy recesses it normally prefers into exposed positions on vegetation. By now, its tentacles, too swollen to be retracted into the snail’s protective shell, closely resemble caterpillars - a tempting morsel for a passing bird and a vehicle for the worm’s entry into its definitive host.

If you smoke 20 cigarettes a day, you will save € 2,080 each year if you quit. In 5 years you could buy a half decent car and in ten years a nice sports model! Since the price of tobacco continues to rise, quitting could buy you a serious motor. Irish Cancer Society in: The MANual on Men for Cancer Prevention and Early Detection

Rather more mundane than the tactics used by Leucochloridium, the all too familiar coughs, sneezes and diarrhoea are symptoms inducedin people by sundry human para-sites whose primary purpose is to affect the transition from one host to another. But not all parsites induce changes in behavior; many either make use of their host’s normal behavior, or infest sub-populations with behavior that serves their needs. Sexually transmitted organisms, including those caused by Human Papilloma and Immunodeficiency viruses, provide examples of this kind as do the blood or liver flukes, whose intermediate hosts are aquatic snails. Only fishermen and farmers who wade in irrigation ditches, or others exposed to water in which larval flukes have been released by snails, are at risk for infestation. All of the human the parasite mentioned, and many more, are associated with specific human cancers. Prevention of these and other cancers associated with human parasites (including microorganisms) can be accomplished by preventing invasion by the parasite. In the absence of a vaccine, this may require changes in lifestyle or personal habits or, in some cases, treatment, as long as re-infection can be avoided. Unfortunately, human behavior is notoriously difficult to change - because of lack of motivation or concern about the financial cost associated with change, or because of real or perceived benefits of the behavior. Explanations and warnings may sometimes work, but targeting specific sub-groups (e.g., young women, adolescents, men) with light-hearted or positive messages that use the techniques of a trickster, and that touch upon issues of particular importance to the target population, may prove to be more effective in promoting the transition to healthier behavior (see panel). Such techniques have been used by the tobacco industry with devastating effect.

Parasitism: a Recursive Ecosystem

The notion that parasites take a “free-ride” on (or in) another organism is at best a gross oversimplification. Parasitism, rather, is a form of recursive coexistence - a process whereby one organism imbeds itself in another. This is of enormous importance to evolution, which is powered by adaptive radiation - i.e., the creation of diverse life forms in relationship to new habitats. In the case of the host/parasite relationship, habitats are provided by the life-forms themselves, thus dramatically expanding the capacity of the ecosystem to support biodiversity and creating new possibilities for cooperation among quite unrelated species in the exploitation of still more habitats. In this regard, parasitism was a key process in a major evolutionary step in which the molecular pathways required for aerobic respiration and photosynthesis, which had evolved in certain prokaryotic cells, were transplanted into other cells. The endoparasites eventually became vital elements of a new cell type - eukaryotic cells - whose properties permitted the cells to associate in a remarkable manner not possible for prokaryotic cells. Plants and animals, comprised of large numbers of highly specialized eukaryotic cells whose lives were ineluctably bound together (and routinely sacrificed for the good of the entire organism) could now emerge.

Notwithstanding the crucial importance of parasitism to evolution, humans tend to have a dim view of the process, since many diseases are caused by human parasites. Under natural circumstances, the closely linked host/parasite relationship hovers around an equilibrium similar to that between predators and their prey, since the goal is mutual sustained survival. The balance is created by the “invisible hand” of nature, whose actions are mediated via numerous genetic and environmental factors that vary among sub-populations of both host and parasite, and in different habitats or regions. Genetic changes in the one (host or parasite) automatically result in the selection of those traits in the other that lead to reestablishment, over time, of the equilibrium. Long-established host-parasite relationships evolve towards benefits to the parasite with no significant harm to the host (commensalism) or to a situation of mutual benefit which can lead to mutual dependence (symbiosis). Conversely, harm, i.e., highly debilitating disease, is more likely to occur when parasites gain access to hosts they do not normally parasitize - either through unusual circumstances, or because one or more specific genetic changes have permitted colonization of a new host. A contemporary example is the transition of HIV from monkeys to humans. This is similar in principle to the entrance of an alien species into a stable ecosystem, either through chance (e.g., inadvertent transportation or migration of several individuals to a new location) or through the rapid emergence, in evolutionary terms, of a new organism. In either case, the resultant disturbance in the ecosystem may be sufficient to cause a significant reduction in biodiversity. The most extreme example of this is the sudden emergence of Homo sapiens, which has resulted in a catastrophic effect on biodiversity of the order of magnitude of previous mass extinctions. Purposeful or inadvertent changes in ecosystems caused by humans (e.g., resulting from the agricultural revolution, or the introduction of alien species into a habitat) have amplified the problem, and have sometimes led to unexpected results, including the potential to increase the risk of cancer (Figure 1). Increasingly, humans have adapted to habitats through the use of tools rather than through genetically driven changes in their bodily structure, thus enabling them to adapt much more rapidly than other organisms and seemingly nullifying, to a large extent, the biological processes that normally lead to a restoration of ecological harmony and to a continuous increase in biodiversity. If this is so, then either human wisdom or human folly will be Nature’s final recourse.

Figure 1. Cascade of effects on the ecology and economy of Lake Victoria resulting from the introduction of the Nile Perch. Civil society has responded: an East African non-profit association, Lake Victoria Organization, has been established to coordinate efforts to save the lake.

Degrees of Freedom

In general, parasites, appear to be an epiphenomenon with respect to the primary food chains. This does not prevent them having a significant influence on the ecosystem with which they are associated. In some senses, parasites might be considered regulatory elements of ecosystems, comparable to the epigenetic regulation of gene expression in cells (which results from chemical changes in the chromosomal environment of genes), a process that, if abnormal, may sometimes contribute to the development of cancer. At a different level, the influence of parasites on ecosystems may also be compared to the modulating influence on human relationships of the ancient paraseitos and their descendants in modern societies - an effect which, at times, has changed the course of human history. These seemingly spurious parallels are not as tenuous as they might, at first, seem, since all three reflect deep biological principles. Evolution occasionally leads to added layers of complexity and, consequently, extraordinary new possibilities, for each additional layer is a system in which the units are the previous systems, and each system is much more than the sum of its parts. In cells, gene-environmental interactions, however complex, are mediated exclusively by molecules. In animals, the evolution of a nervous system permits higher order behavior and maximal use of form and physiology. Behavior now, can be based on learning (which involves memory) and even an element of freedom of choice. Freedom of choice is most highly developed in humans - so much so that mind, as articulated by Descartes, was, until recently, thought to be quite separate from the physical structure of the brain and therefore not a biological phenomenon; freedom appeared to be unrestrained. Today, the conclusion that behavior, including social behavior, has a genetic foundation in all animals is inescapable, although this becomes less apparent as the importance of learning increases. In ants and bees, where learning is confined to tightly prescribed circumstances (e.g., in pathfinding), genes influencing behavior have already been identified. In humans, correlations between brain structure and function have been known since the nineteenth century, but correlations between brain physiology and certain types of behavior (including social or “ethical” behavior) have only recently been made and studies of the genetics of behavior are in their early stages. A principle, however, seems to be emerging: genes can influence what can be learned and how well, and probably also confer constraints on imagination, which, after all, is merely the recombination of remembered ideas. Freedom is limited.

The Community as Individual

Animal communities are also recursive in the sense that they are comprised of individuals within a system that functions as an individual in the context of the larger ecosystem to which it belongs. Consequently, the well-being of the community is more important than that of the individuals who comprise it. The importance of community to humans could not be greater, although it is often taken for granted. Almost all human endeavors are cooperative, either in real time or over time. Millions have contributed in the course of millennia to the evolution of complex machines from paleolithic axes, permitting the automation of manufacturing and a resultant enormous leap in productivity. And just as co-evolution (e.g., of animals and plants), with respect to both structure and function, has led to wider and more rapid colonization of the planet by living organisms, so the combination of community and communication (through language) has been central to human cultural evolution and dispersal. But this very success has ensured that expanding communities will increasingly compete for territory or ideas. Communities, like individuals, may also become diseased - i.e., individual benefits of a particular element of society become increasingly separated from community benefits (a parallel to cancer in individual organisms and to imbalance in ecosystems). New community elements introduced from other communities are not unlike parasitism. The ability of a community to defend itself against disease, e.g., by turning “parasitism” into symbiosis, or maintaining balance in its component parts, depends upon the strength of its institutions and the mechanisms it uses to retain its integrity. One of these mechanisms is civil society.

Civil Society

The nature of human society has been debated since antiquity. Aristotle, in the Politics, describes the Greek communities living in city- states - polis -, as “an association of associations.” He believed that the natural tendency of people to live together in communities allowed them sufficient security and stability to be able to pursue “virtuous acts”- i.e. those acts required of them as citizens, which provided benefits to both the individual and the community. The walled city-states, common to all ancient civilizations, had evolved from the earliest agricultural settlements. Their well planned streets and substantial communal buildings (including temples) reflected the underlying sociopolitical structures, while their small size compared to modern states ensured that the benefits of the polis (which did not, incidentally, include slaves and foreigners) to the individual, and vice versa, were obvious to all. Aristotle regarded the polis as "civil society" in contradistinction to the animal-like state of the outlying tribal communities, which at times amassed into large groups capable of laying waste to the city-states. The classical concept of civil society, then, which persisted well into late medieval and Renaissance Europe, encompassed both the government and the governed. Hobbes perspective, for example, was not greatly different from Aristotle’s. He referred to civil society in the context of politically organized commonwealths in which the sovereign authority could legitimately take from its citizens what was needed in order to command the necessary power to overcome the “.... dissolute condition of masterless men without subjection to laws and a coercive power to tie their hands from rapine and revenge.” Hobbes was under no illusions with respect to the rapine and revenge that sovereign powers (whether a man or an assembly of men) could heap upon each other, but did not feel this to be incompatible with sound government within the commonwealth.

Government ¹ and ² Ratification of the World Health Organization’s Framework Convention on Tobacco Control Introduction of legislation pertaining to tobacco use as per the FCTC Introduction of legislation pertaining to other risk factors (e.g., chemical exposure) Introduction of legislation ensuring opioid availability for palliative care Establishment of a National Cancer Control Committee Implementation of the World Health Assembly Resolution of May 2005 on cancer prevention and control; in particular, development and implementation of a national cancer control plan ³ Ensure appropriate educational systems for health professionals are in place Coordinate the evolution of an equitable health system Ensure, as far as possible, that institutions needed for cancer control are established Ensure, to the extent possible, that necessary equipment and drugs are available Ensure highest possible level of access of the population to appropriate cancer care Provide moral and financial support for cancer control Civil Society Advise the government with respect to the importance of cancer as a health problem Advise and support the government with respect to its role in cancer control Ensure access to, or collect relevant data on which to base the cancer control plan Undertake demonstration cancer control projects that, if successful, can be scaled up Disseminate results of cancer control projects Develop or participate in the development of guidelines on how to establish and implement cancer control programs Encourage collaboration of all societal elements in cancer control Participate in or support relevant professional and public education Provide psychosocial support to patients Participate in service delivery Raise funds from the public, government and industry for cancer control Industry Provide effective products for cancer control Conduct or support locally relevant research involving its products Participate in professional education relevant to the conduct of relevant research Provide selected services Provide unrestricted financial support to civil society ¹ These roles are not exclusive, and frequently overlap ² This is not an exhaustive list ³ 100 countries had already ratified the convention by the deadline of November 8th 2005

Table 1. Some of the Roles of Societal Elements in Cancer Control.

The rapid growth of the merchant classes between 1750 and 1850 caused a major restructuring of society and a significant modification to the concept of civil society. Increasing mobility resulted in communities being frequently comprised of strangers rather than families living in close proximity for their entire lives. Meanwhile, the newfound wealth of the merchants and their desire for independence from the ruling classes, coupled to changes in the traditional hierarchical structures brought about by the French and American revolutions, led to rapid growth in the number of voluntary associations, particularly in the United States. Their role was seen as confronting and curbing the power of centralized government, particularly with respect to newly realized individual rights and freedoms (although, as in the city-states, such rights were not accorded to all inhabitants). Alexis de Tocqueville, a Frenchman sent to observe the American social experiment in the early 19th century, was particularly impressed by the number of such associations he found, and he and many of his contemporaries came to view these associations, rather than the state as a whole, as constituting civil society - a view that was reinforced in a later era in the context of Eastern European dissidents. Although merchants continued, for some time, to be considered part of civil society, the growth of commercial organizations to the point that many came to straddle communities, and even states, and often held considerable sway over governments on issues affecting their own well- being, led to a further narrowing of the concept of civil society. It is now generally considered to include only the complex of voluntary associations (non-governmental, non-profit organizations being, for many, the central element), that provides the public with both a voice and the ability, through raising awareness and mobilizing resources, to influence a broad range of societal issue, particularly in the domains of justice, equality and health. And although the boundaries of civil society are imprecise and vary in different cultures, it embodies the idea that individual freedom is possible only in the context of a healthy community, the creation of which is its primary purpose.

Not all voluntary associations are directed towards goals that will benefit society and a strong argument can be made for limiting the definition of civil society to those associations devoted to the public good. This includes responsible journalism,which should ensure that the public are well-informed on a variety of issues that affect their well-being. But if voluntary associations are to have a positive impact, they must embody more than simply good intentions. They must be managed, or at least advised, by persons with appropriate knowledge and skills, and remain free from excessive influence by patrons (e.g., through seeking at least some of their funds directly from the public). Many professional associations, for instance provide a unique repository of knowledge and skill that is likely to greatly exceed that of the government in specific areas of endeavor, such as health, education, science and human rights. Even when professionals are employed by the government, their powers as employees differ greatly from those of the professional associations to which they belong. But as long as governments maintain a monopoly on legislation and coercive powers, the influence of voluntary associations should not be overestimated. Nor should the dependence of civil society on both government and industry be underestimated. Civil society requires at least a tolerant government, and better, a democratic form of government, if it is to grow and develop, or even openly exist. At it’s best it can do much to lessen inequalities and to promote causes that may be overlooked by the government, purposely, or through lack of knowledge. It may also draw attention to societal diseases. Some of the roles of civil society in cancer control are shown in Table 1.

Global Civil Society

Broad international consensus is essential to dealing effectively with the overarching issues of human rights, poverty, equality of opportunity, peace and security, health, economic globalization, environmental protection, climate change and nuclear proliferation, for each of these transcends national boundaries. Consequently, none of these problems can be effectively addressed without simultaneously addressing the problems of developing countries. A particular problem of our times is the frequent close relationship between big business and government. This creates the potential for serious societal injury for each tends to foster it’s own interests (respectively, power and profit), with limited regard for weaker elements of society represented, at a global level, by developing countries. A three-way alliance among government, industry and civil society is likely to lead to a healthier society. In the international arena, an intergovernmental organization (i.e., a voluntary association of governments), the United Nations (UN), takes the role of national governments in states, but its power is determined by the extent to which individual governments are willing to cede their powers. This tends to be inversely proportional to their global influence, i.e., the richest and most powerful countries are the least willing to yield to international consensus. A healthy global civil society, comprised of international organizations and international networks of national organizations, is needed to strengthen existing intergovernmental organizations and to advocate and act on behalf of a global "good" society that strives to reduce inequities and to address problems that threaten to cause, or are already causing, serious damage to the planet and its people. Cancer is just one of these. Fortunately, the marked increase in the number of non-governmental organizations in consultative status with the UN in recent decades suggests that civil society is alive and well and rapidly becoming a major actor on the world stage (Figure 2).

Figure 2. Numbers of various type of NGOs in consultative status with United Nations Economic and Social Council by year.

Biology teaches us that diversity creates new opportunities for collaboration, for creation and for mutual evolution. Civil society, with its variegate and ever-changing form can be seen as the human equivalent of the biological invisible hand that leads to ecological harmony, although mind-born, its strategies are based on observation and intelligent intervention. The remnants of the polis, fused now into human society in its entirety, just as the prokaryotic cells that had learned to derive energy directly from the sun and to breath the resultant oxygen were fused into eukaryotic cells, give hope that the era of individualism in which we live will prove to be the adolescence of the human race - one that, with the trickster’s help, will bloom into a maturity in which human beings become stewards of the planetary ecosystem rather than it’s despoilers.