Year in Review (2021)

 

Time for my annual “year in review” blog!

In many respects the year 2021 felt like a repeat of the year 2020 (sigh!), as half of both years were spent in isolation, lockdown and me doing online teaching and my kids at home doing online learning [sic].  After a brief 3 month stint with in-person teaching from Sept- November, it looks like I will be going back to online teaching again to start the 2022 academic year (this despite the University having imposed a vaccine mandate and mandatory face mask policy on all faculty, staff and students back in Sept 2021).   

The mantra “you can never be too cautious” seems to be the default mode of reasoning for our province’s public health experts and politicians for the past 18 months, and sadly it has (IMHO) demonstrably proven itself to be a failed mode of reasoning and rather ineffective way of communicating to the general public how to responsibly balance different types of risks and benefits.  The narrowly conceived public health goal of success since May 2020 has been equated with “not overwhelming healthcare with severe COVID-19 illness”, but this has overlooked the reality that the mental health toll of the prolonged mitigation efforts (which will be measured in years, not months or weeks), especially on the young, to delay the spread of the virus has also increased demands on healthcare though sadly little, if any, support has been available.  So our long-term “delay the spread of the virus indefinitely” strategy has been compounding many pre-existing (and very serious) public health problems.  The irrevocable negative impact on childhood, adolescent and young adult obesity rates, education and development, as well as mental health will be devastating for a whole generation.     

Tragically I think it will be many more years before an impartial and evidence-based assessment of these issues can take place.  At the moment most are still in the grips of fear of a virus we still do not know very much about, and thus the precautionary principle has been peddled as responsible public health decision-making to make folks at least feel safer.              

The big new development with the pandemic in 2021, beyond the media obsessively tracking and reporting all the “variants of concern” (first Delta, and then the ominous sounding OMICRON) was the COVID-19 vaccines, hailed as the solution out of the pandemic once sufficient numbers of people were vaccinated.  Contentious debates and policies pertaining to vaccine passports, and then boosters, ensued.  And thus 2021 ends with record-breaking numbers of positive cases in my city and province, but the impact on serious illness and death remains to be observed and assessed.    

Despite the persistence of this pandemic for 2+ years, I still stand by my initial assessment that COVID-19 itself is not the most significant public health predicament of the past century, nor of today (which does not imply that it is not a significant public health problem, it certainly is (especially for older populations)). 

However, there is one caveat I will add now given how things have played out since May 2020- if we include the adverse health, educational and financial consequences of the prolonged mitigation measures most developed countries have pursued for nearly two years- such as  the impact on anxiety, isolation, mental health, obesity, suicide, domestic abuse and marital breakdown, unemployment, educational deficits, delays in other medical interventions, impact on the economy, etc.- the pandemic’s full impact is significantly larger.  My initial assessment did not anticipate that countries would pursue a strategy of long-term virus mitigation until vaccines (and then boosters) were widely available and beyond.  To be honest if you had asked me back in May 2020 what the chances were that such a strategy would have been adopted long-term (that is, after the initial 3 month lockdown (when little was known about SARS-CoV-2) I would have said “zero”.  That was my view not simply because of the clear adverse side-effects of such policies on mental health, liberty and the economy, but because there was no empirical basis for thinking such a strategy was viable in the long-term (in terms of both compliance from the general public and in terms of doing anything other than simply delaying the spread of the virus till such measures were relaxed).  Unfortunately the adverse health impact of these mitigation measures will persist for years after the public’s fixation on SARS-CoV-2 (and the virus’s evolution) has dissipated.  We could call this effect “Long COVID lockdown”.  But, I digress!

Watching the mental health toll of the lockdown measures- on family members and friends, and my students and reading the rapidly emerging data from empirical studies on these effects (on anxiety, addictions, obesity, undiagnosed diseases, etc.)- has been absolutely devastating to witness.  I intend to spend the next decade of my research canvassing the toll of both the virus and the public health successes, experimental “pivots” and disastrous blunders.  What I had thought would initially be a 1-2 year research project will now take probably closer to 10 years to research, write and complete.  I have decided to prioritize doing a competent and thorough job of analyzing these empirical and policy issues vs just rushing to get something published. 

In the coming winter (2022) term I am teaching a new 4^th year seminar titled “The Politics of Pandemics and Epidemics” which applies a public health ethics lens to the societal challenges of mitigating the health risks from 4 infectious diseases (malaria, HIV/AIDS, Ebola and COVID-19) and 3 non-infectious “epidemics” (obesity, the “war on drugs” and gun violence).  Teaching this new course regularly will permit me to expand my public health research interests beyond the issues I have focused on for the past 20 years (e.g. the genetic revolution and aging research).       

Despite the continued upheaval of the pandemic, I was inspired on both the teaching and research fronts in 2021.  In the winter term of 2021 I continued with my online teaching, especially for the large class of 270 students, designing extended lecture videos on Rousseau, Burke and conservatism, Black political thought, Wollstonecraft and feminism, utilitarianism, Marx and Fanon. 

2021 proved to be an exceptional year for my research and writing.  As an introvert I was fortunate to be able to make the most of the time in isolation by diverting my energies almost exclusively to reading and writing.  I published my first article on the COVID-19 pandemic, and wrote (and then had quickly accepted for publication and actually published) 2 articles on the 50^th anniversary of “the war on cancer” (here and here).  And a book chapter on toleration also appeared in print, a long article on how to theorize about justice in the genome era, and I wrote the first draft of half of a new textbook on the history of political thought (this project will consume most of my attention through 2022).  The year 2021 was probably my most productive year ever for research, because there wasn’t much else I could do for most of the year.   

What will the year 2022 bring?  In terms of science and innovation, I am hopeful serious progress will continue to be made with respect to the development of an applied gerontological intervention.  I still maintain that such an intervention will end up being this century’s most significant advance in public health because advanced age is the most significant risk factor not only for cancer and COVID-19 mortality, but for most disease, frailty and disability.  This is not a story you are likely to hear in the evening news.  But what gets “clicks” on news stories, or “likes” on social media often bears little, if any, resemblance to what is actually going on, from a “big picture” perspective, with today’s aging populations. 

I am optimistic the year 2022 will see us at least get into a different collective mindset about (i.e. accepting that we must learn to live with SARS-CoV-2 and return to normal life) this pandemic, given that the ending of this pandemic will not likely be televised. All the best for a New Year!

Cheers, 

Colin

50 Years of the other "C-Zero"

If you had 10 Canadians gathered together in a room, and you asked “How many of you think you will develop cancer?”, odds are no one would raise their hands. 

Like divorcing after marriage, no one thinks they will get cancer (or divorced!).  But like divorce, cancer is something many people will experience (4 out of 10 Canadians), and a few will even have multiple cancer diagnoses (and divorces!).  Approximately 2.5 out of 10 of my compatriots will die from cancer.(stats here)

Cancer is not only a problem for my compatriots.  Globally cancer kills approximately 10 million people every single year.  Cancer is the second leading cause of death in the world.  Nearly half-a-century ago President Nixon declared a “war on cancer”, the goal of which was to eliminate cancer as a cause of death.  Let’s call this project CANCER-ZERO.  The video above outlines the first 40 years of this campaign.

50 years later, with billions of research dollars being invested in cancer research every single year for nearly half a century, not a not a single type of the 200+ types of cancer have been eliminated.  Not a single one.  Let that sink in.  It is reason for humility, humility for how little we truly understand the complexities of our biological lives and humility for what science can realistically deliver. 

In the video Dr. Otis Brawley, then Chief Medical Officer of the American Cancer Society remarks:  

“I wish that we had tried to convince people that this was an investment in research that was long-term. I wish some people had not assumed we would make tremendous insights very quickly. Unfortunately human nature is such that if people had realized that this was a 40, 50 or 60 year commitment they would not have gone for it”.    

Despite the failure to realize CANCER-ZERO, the war on cancer has brought significant improvements in preventing, diagnosing and treating cancer.  We now know we can reduce some cancer risks through smoking cessation and other lifestyle changes (e.g. exercise, diet, etc.).  Improvements in diagnostics can help us catch cancer in the earlier stages of development, which makes a significant difference for survival rates.  And better cancer treatments have been developed, improving survival and quality of life for cancer patients.

50 years of the “war on cancer” has taught us that CANCER-ZERO is more of a fantasy than a feasible public health aspiration.  And the fact that most people go about living their lives in denial about their cancer risks is a mix of good and bad news.  It is good news because you do not want people ruminating about their 40%+ lifetime risk of cancer!  But at the same time, you want folks to be aware of the reality that their lifestyle choices can modulate their cancer risk factors (increasing or decreasing them).

And this takes us to the final and most significant reflection on the war on cancer.  50 years of rising cancer deaths have made vivid the importance of aging as the most significant risk factor for cancer (as well as the other diseases of late life).  I already wrote plenty about that earlier this year, so if you would like to hear more feel free to check out this article and this article.

But cancer is not exclusively a disease of older persons.  The latest issue of Lancet Oncology has this comprehensive study on the global cancer burden in adolescents and young adults (aged 15–39 years). In 2019 there were approximately 1.19 million cancer cases and 396 000 deaths due to cancer among people aged 15–39 years worldwide.

Let us see where the next 50 years of public health and advances in the biomedical sciences take us!

Cheers

Colin

Framing an Aging Intervention (reflections 2)

 

For many years now I have been a proactive champion of the scientific field of study that I think will have the most significant impact on the health and economic prospects of humanity this century- “geroscience” and an applied gerontological intervention that retards the rate of molecular and cellular decline.  

And a great deal of my research has focused on the societal challenges of framing, and prioritizing, this area of science when most people do not even perceive the harms of senescence as a public health problem, are mostly ignorant about the biology of aging and are unaware of the recent scientific discoveries in altering the rate of aging. 

What is worse than indifference to this area of scientific research is the open hostility and opposition people (even eminent "public intellectuals") often have towards it.  And this blog post addresses this concern by noting that much hinges on how one “frames” the moral imperative to alter aging.

        To cut the chase, the wrong question to ask, in my opinion, is to ask- “Should we pursue life extension?”  This is the wrong question to ask because it is ambiguous, and thus it is likely to be prone to skewed moral evaluations of the stakes involved with “extending life”.  For example, some might interpret this question as asking them if they would want to life forever, to be immortal.  Others might, reasonably, infer the question implies an extension of the period of frailty, disease and disability at the end of life by delaying death for as long as possible.

        Because the aspiration of “life extension” lacks precision, talk of “life extension” typically raises a wide array of intuition-based concerns, such as whether we would be bored living hundreds of centuries, or how this would likely impact the global population size and environment, etc., or if this would create a new caste society between those with “normal life” and those with “extended life”.

            The proper way to frame the moral imperative to retard human aging is to ask the right question.  And that question is:  “Should we aspire to reduce the risks of morbidity, frailty and disability in late life?”  The answer to that question is “Yes, of course we should!” 

            To make vivid the different moral stakes at interest between the aspiration to “life extension” and increasing the human “healthspan”, compare the contrasting moral sensibilities the following two aging scenarios invoke.  The first scenario (Scenario 1) describes what many would take to be a dystopic life extension future, and the second scenario (Scenario 2) is a more utopian one.  It is the latter that an applied gerontological intervention could help us realize, but the “aging status quo” is taking us in the direction of (a less extreme version of) Scenario 1.

Scenario 1:  Extended Life = Extended Survival (accompanied by extended and more severe frailty, disease and disability)

Over the next half a century population A increases its life expectancy at birth by 40 years, from age 80 to age 120.  This increase in life expectancy is primarily achieved by simply forestalling death in late life.  The procurement of additional decades of life in late life is achieved not by altering aging, but from advances in improving survival to the upper limits of maximal longevity.  Through a combination of novel and expensive drug development, coupled with extensive public health expenditures in long-term care facilities and palliative care, patients can now survive for decades on chemotherapy and radiation, reliant upon ventilators, etc. enduring dementia and other severe diseases, frailty and disability for decades.  The majority of the people surviving past age 110 have little psychological continuity to their former selves, as new diseases of the brain emerge with the extreme longevity achieved (but with minimal improvements in treating these cognitive disorders). 

The only real achievement for population A in this scenario, from a population health perspective, is increased survival and a prolongation of the period of disease, frailty and disability in late life.  The “longevity dividend” (Olshansky et al 2007) achieved in society A is very costly, with ever increasing healthcare expenditures being invested in preventing death in late life with little to no regard for the “quality of life” of people in late life.  Family members learn to normalize the practice of spending many decades visiting family members in long-term care facilities, and those family members over age 100 typically can not live independently and many are no longer capable of actively participating in family life. 

Consider now a contrasting future of life extension: 

Scenario 2:  Extended Life = Extended Healthspan (increasing health and decreasing frailty, disease and disability).

Over the next half a century population B increases its life expectancy at birth by 40 years, from age 80 to age 120.  This increase in life expectancy is primarily achieved by extending the human healthspan, which means a substantive delay and compression of disease, frailty and disability in late life.  The procurement of additional decades of life is achieved by a relatively inexpensive drug that re-programmes the human metabolism to mimic the longevity effects of caloric restriction (without people having to endure the deprivation of actually consuming less calories than that required for a normal diet).  With this public health advancement it takes the average person 120 years to biologically age what use to be achieved in 80 years.  Furthermore, at the end of life there is a compression of morbidity, meaning the period of time people suffer age-related health maladies (e.g. disease, frailty and disability) is shorter than the period they experienced before the aging intervention.  Thanks to this aging drug, most people will be capable of working well past age 100, though many decide to spend the additional years of healthy life volunteering in their communities, helping out with childcare duties for their grand and even great grandchildren, etc. 

People in this second scenario enjoy more health in late life, and thus the “longevity dividend” in population B also brings significant economic benefits.  By expanding the opportunity for people remaining productive in late life, and reducing the public expenditures typically spent helping persons manage the co-morbidities of late life, population B reaps significant economic, as well as health, benefits.   

The two contrasting scenarios of populations A and B are deliberately exaggerated in terms of stark negative and positive health and economic outcomes, to reveal how such details activate different moral sensibilities in terms of our considering the desirability of “life extension”, for both individual lives and populations.  Population A realizes perhaps the worst outcome most people could envision for aging populations- prolonging the suffering, disease and frailty of diminishing health in late life at an exorbitant social cost.  Such a society fanatically values “quantity” of years survived over the “quality” of the life lived, something most people would disagree with.  Surviving many additional decades of life with progressive and severe infirmities and minimal psychological wellbeing is not something most people would see as a desirable outcome.

The “longevity dividend” realized in scenario A is one that prioritizes “adding years to life”  instead of “adding life to years”.  Scenario A is not a cost-effective, nor morally laudable, aspiration.  The quality of life secured by the 40 year increase in longevity is very relevant to our assessment of the value of such an increase in the lifespan.  And with the details provided in Scenario A, many people might (reasonably) take the view that the society would have been better off not aspiring to increase life expectancy further than the original age of 80 years.

In scenario B the “longevity dividend” is the opposite of that in A.  Population B realized the goal of “healthy aging” vs simply delaying death.  The health benefits secured in B are meaningful and substantive because people enjoy more health, and thus life extension is simply a by-product of increasing the healthspan vs the intended goal.    The reason I believe geroscience is the most significant area of scientific research, and an applied gerontological intervention the most important public health intervention of the 21^st century, is that such an intervention could make a future like Scenario B a reality.  No cure for any specific disease of aging would come even close to making this a reality.  In fact a cure for just one disease of aging is compatible with the realization of the dystopic future described in Scenario 1.  But an intervention that simultaneously delays and compresses the diseases, frailty and disabilities of late life will could a significant health impact on the 2 billion people who will be over age 60 by the middle of this century.                                                                                                 

Cheers,

Colin