Descartes’ Error

I can’t remember why, back in 1995, I bought a copy of Antonio Damasio’s book, Descartes’ Error.  Was it the cover, with a Renaissance-style portrait overlain with symbols, geometric constructions, and a strange dark block obscuring the eyes?  Was it the subtitle – Emotion, Reason and the Human Brain – that caught my attention?  While I would like to think that it was the content, which addresses how the social mind affects and shapes rational analysis and behaviour, I suspect it was because it opened with a discussion of Phineas gage.  Gage was a blue-collar worker man, employed in the building of a railroad,  who had an iron tamping bar explode into his skull, entering from below his cheek and exiting through the top of his head.  Remarkably, he survived the accident, with the result that he was to become one of the most famous cases in the history of brains and behaviour.

The story of Phineas Gage is quite extraordinary.  He was working as the foreman of a railway gang in the summer of 1848, employed to construct a new railway line in Vermont.  His key responsibility was to insert an ‘ex[plosive powder’ into each hole drilled by the team, so that the rock along the intended line could be destroyed.  Momentarily distracted when tamping down the powder, he knocks his iron tool against the rock, and the resulting spark immediately creates an explosion, shooting the tamping iron into the air.  Gage wasn’t killed but is thrown backwards as the iron bar leaves through the top of his head.  After a few ‘convulsive motions’, he sits up, speaks to the people around him and then sits upright in the cart that took him to be seen by a doctor.

The top of Gage’s skull has been blown off, and his brain can be seen pulsing within his skull.  That tamping iron was three feet seven inches long (a little over a metre) and weighed thirteen and a quarter pounds.  That he survived is almost impossible to believe.  He was to experience a fever from the infection of the site, but within two months he is fully recovered, physically recovered, that is.  He regained his strength, and could use his senses, with the exception of his left eye, which was damaged in the accident.

However, the psychological changes were profound.  Prior to the accident, Gage had been considered ‘”temperate of character”, shrewd, smart and very diligent.  After, he was transformed, and the physician’s report noted he was now “fitful, irreverent, indulging at times in the grossest profanity which was not previously his custom, manifesting but little deference for his fellows, impatient of restraint or advice … at times pertinaciously obstinate , yet capricious and vacillating … a child in his intellectual capacity and manifestations, he has the animal passions of a strong man”.

Sadly, the rest of his life was a spiral downwards.  He worked for a while on farms, and then became an attraction in a circus.  He left that life to work with horses in South America, and eventually returned to California in 1960 to live with his mother.  He began to experience seizures, and died in 1861, just 38 years old.  While physically it seems he largely recovered from his accident, Phineas Gage was no longer the individual he had been before his accident:  we would say he was a ‘different person’.  Indeed it is the relationship between his recovery from the bodily consequences of the accident and the change in his personality that was to make him such an important figure in conjectures about the role of the mind, and the reciprocal impact of the brain on the body.  Important in the sense that the aftermath of his accident was to lead to changes that were hard to understand at the time, and which remain a puzzle today.

Such an extraordinary case could not be taken much further at the time, as Gage was buried in 1861, without an autopsy.  However, it was Damasio’s sister, Hanna, who was to undertake a brilliant reconstruction of the accident, using Gage’s skull.  By painstaking reconstruction of the remains, working with a number of collaborators, she was able to show that it was almost certain that it was selective damage in the prefrontal cortices of Gage’s brain that had compromised “his ability to plan for the future, to conduct himself according to the rules he had previously learnt, and to decide on the courses of action that ultimately would be the most advantageous to his survival” (page 33 of Descartes’ Error).

Damasio was then to have a second case to examine, but now a contemporary one.  This was the case of Elliot, a man in his thirties, who had been referred for study as the result of a ‘radical change of personality’.  Elliot had been an intelligent, skilled and able bodied man, and when Damasio saw him had an excellent memory about the world, and had kept his considerable business skills.  However, he had begun to lose concentration at work, and also his sense of responsibility.  This was diagnosed as the result of a rapidly growing frontal lobe tumour.  Surgery was required, and as a result he had the tumour removed, as well as frontal lobe tissue.

After surgery his skills and use of language was unchanged.  However, his personality was completely different.  He needed continuing prompting, to get up, to go to work, to keep working. He could no longer follow a schedule, and he would easily slip from one  activity to another without completing either.  He could understand the material and tasks he was given, but would change to something else almost on a whim.  He lost his job, and tried various foolish and unsuccessful ventures.  He commenced a series of marriages and divorces.  Damasio describes him as a new Phineas Gage “fallen from social grace, unable to reason and decide in ways conducive to the maintenance and betterment of himself and his family, no longer capable of succeeding as an independent human being.”  As had been likely with Gage, it was clear that in Elliot’s case parts of his frontal lobe were removed, but no other part of is brain.  It was as if he had “a new mind”.  In time, Damasio concluded that his intellectual abilities were undamaged, but his responses had changed, and he was experiencing reduced emotions and feelings.  He was ‘another Phineas Gage’.

Antonio Damasio is a Portuguese neuroscientist.   His interests are n neurobiology, especially the neural systems which underlie emotion, decision-making, memory, language and consciousness.  He has developed what he calls the ‘somatic marker hypothesis’ a theory about how emotions and their biological underpinnings are involved in decision-making (both positively and negatively, and often non-consciously).  Central to his approach is the view that emotions provide the basic scaffolding for social cognition and the self-processes which underpin consciousness.  His approach offers a scientific basis for the linkage between feelings and the body, offering evidence showing the connection between mind and nerve cells … what he calls the “personalized embodiment of mind.”.

It has been groundbreaking work.  Current work on the biology of moral decisions, neuro-economics and social communication have drawn on his work.  He has proposed that our emotions and feelings as a read-out of body states.  In a later book, The Feeling of What Happens, he laid the foundations of what he describes as the “enchainment of precedences”: “the nonconscious neural signalling of an individual organism begets the protoself which permits core self and core consciousness, which allow for an autobiographical self, which permits extended consciousness.  At the end of the chain, extended consciousness permits conscience (271-271, The Feeling of What Happens).

His work is complex and challenging, but the implications of his approach are clear.  It’s a reflection on Descartes (and hence the title of the book).  Descartes based his philosophy using a single first principle: he thinks., best known as the statement ‘Cogito, ergo sum”  (I think, therefore I am).  Central to this perspective was the notion of doubt:  Descartes concluded, if he doubted, then something or someone must be doing the doubting; therefore, the very fact that he doubted proved his existence.  “The simple meaning of the phrase is that if one is skeptical of existence, that is in and of itself proof that he does exist.” (Principles of Philosophy, Part IX).  Descartes concludes that he can be certain that he exists because he thinks. But in what form? He perceives his body through the use of the senses; however, he comments that evidence suggests that the senses are unreliable.  Given this, the only knowledge on which we can rely is through thinking.  Thinking is seen as every activity of a person of which the person is immediately conscious

Damasio’s approach upsets that apple cart.  We are a long way past Descartes’ musings (well, perhaps I should say his philosophical explorations).  Today many want to argue that we are simply data processing machines, AI systems, with our bodies the equivalent of electrical power generators.  In that perspective, ‘mind’ is something to be explained away, a peripheral and rather uninteresting phenomenon.  It’s a dull and dehumanising view.  Indeed, it reflects an even broader understanding, the depressing expectation that soon we will be able to explain humanity, life on earth, and even the secrets of the cosmos at both the level of elementary particles and the cosmos as a whole.  Once the view of the world was it was turtles all the way down; now it’s AI all the way up!

If Damasio’s views are subtle and complex, they make a reassuring contrast to those of some scientists who claim that new discoveries have proved free will is an illusion.  In large part, this is an argument about genetics.  If Damasio offers and nuanced and complex view, there are others who take a far simpler approach, suggesting that many of our traits are more than 50% inherited, including obedience to authority, vulnerability to stress, and risk-seeking. Researchers have even suggested that when it comes to issues such as religion and politics, our choices are much more determined by our genes than we think.

Many find this disturbing. The idea that unconscious biological forces drive our beliefs and actions would seem to pose a real threat to our free will. We like to think that we make choices on the basis of our own conscious deliberations. But isn’t all that thinking things over irrelevant if our final decision was already written in our genetic code? And doesn’t the whole edifice of personal responsibility collapse if we accept that “my genes made me do it”? One source of insight on this comes from the experiences of identical twins.

When Professor Tim Spector started his research on identical twins in the early 1990s, he soon was able to confirm that identical twins were always more similar than brothers or sisters or non-identical twins.  As he collected the evidence, his research was undertaken around the time of an emerging  consensus was that genes were an important determinant of who we were, a view promoted by advocates like Richard Dawkins.   His research was also being built up at around the time of  the launch in 1990 of Human Genome Project, setting out to map the complete sequence of human DNA.  This was a decade of optimism, when Daniel Koshland, then editor of the prestigious journal Science, captured the mood when he wrote: “The benefits to science of the genome project are clear. Illnesses such as manic depression, Alzheimer’s, schizophrenia, and heart disease are probably all multigenic and even more difficult to unravel than cystic fibrosis. Yet these diseases are at the root of many current societal problems.” Genes would help us uncover the secrets of all kinds of ills, from the psychological to the physical.

By 2000, genes were no longer regarded as the key to understanding health, but they had become the key to unlock almost all the puzzles of human development and illnesses. For just about every aspect of life – criminality, fidelity, political persuasion, religious belief – scientists were writing papers to claim to how genes were the cause of what was being observed.  Perhaps the ‘high spot’ in this came in 2005 in Hall County, Georgia, when Stephen Mobley sought to avoid execution on the grounds his murder of a Domino’s pizza store manager was the result of a mutation in the monoamine oxidase A (MAOA) gene.  While the judge Refused his appeal, the idea that the low-MAOA gene is a major cause of violence has become widely accepted, and it is now commonly called the “warrior gene”.

In recent years, belief that genes are basis for explaining almost everything about human development and behaviour  has waned.  In part this is because continuing research has revealed almost all inherited features or traits are the products of complex interactions of numerous genes. However, the fact that there is no one genetic trigger has not by itself undermined the claim that many of our deepest character traits, dispositions and even opinions are genetically determined. (This worry is only slightly tempered by what we are learning about epigenetics, which shows how many inherited traits only get “switched on” in certain environments. The reason this doesn’t remove all fears is that most of this switching on and off occurs very early in life – either in utero or in early childhood.)

In more recent years, Spector’s work has focussed on  heritability. We are often told that many traits are highly heritable: happiness, for instance, is around 50% heritable.  What does that mean?  It  is easy to assume that if, for example, autism is 90% heritable, then 90% of autistic people got the condition from their parents. But heritability is not about “chance or risk of passing it on”, says Spector. “It simply means how much of the variation within a given population is down to genes. Crucially, this will be different according to the environment of that population.

Spector spells out what this means with something such as IQ, which has a heritability of 70% on average. “If you go to the US, around Harvard, it’s above 90%.” Why? Because people selected to go there tend to come from middle-class families who have offered their children excellent educational opportunities. Having all been given very similar upbringings, almost all the remaining variation is down to genes. In contrast, if you go to the Detroit suburbs, where deprivation and drug addiction are common, the IQ heritability is “close to 0%”, because the environment is having such a strong effect. In general, Spector believes, “Any change in environment has a much greater effect on IQ than genes,” as it does on almost every human characteristic.

Discounting a simplistic belief in causation by genes has been one significant development in recent years.  However, most researchers are still far from catching up with Damasio’s work.  If we are now coming to a much better understanding of what complex factors affect the developments and disorders of the body as a physiological system, Damasio’s work on consciousness takes a further step.  In suggesting that the roots of conscious are feelings, we are on the edge of confronting some critical puzzles.  Damasio suggest three in particular.   What are feelings made of?  What are feelings the perception of? Finally, and perhaps most important for future research, ‘how far behind feelings can we get’. For me, Damasio is one of the most exciting scientists working on the cutting edge of understanding consciousness.

Awakenings

Although the evidence suggests its impact may be abating, we are all well aware of the COVID-19 pandemic, a global disease resulting from infection by the severe acute respiratory syndrome coronavirus (SARS-CoV-2).  First known to have emerged in an outbreak in Wuhan, China, in December 2019, it rapidly spread worldwide in early 2020.  The World Health Organisation has determined it has caused more than 7 million confirmed deaths by early 2024, and it ranks it fifth in the list of the deadliest pandemics and epidemics in history.  The worst of those we know about was the Black Death, an outbreak of the Bubonic Plague in the middle of the 14^th Century, the same disease that spread through the world in the middle of the 5^th Century (the Plague of Justinian) which ranks third.  Second on the list is the Spanish Flu, which swept across the globe in 1918-1920, and the fourth was the HIV/Aids epidemic, which probably began in began in 1981, and continues today.  All these events are horribly familiar, three of which occurred in the past one hundred years.

However, there have been some other epidemics in the past century that have received less press.  Among these, one of the most remarkable, and least well understood, was Encephalitis Lethargica, an atypical form of encephalitis.  It was a disease that attacked the brain, leaving  people in a frozen, statue-like condition, often speechless and motionless.  It spread around the world between 1915 and 1926, but attention was soon deflected from EL to the Spanish Flu.  The exact number of people infected is unknown, but estimates suggest that more than one million people contracted the disease, which directly caused more than 500,000 deaths.  Of the survivors, most never recovered to their prior vigour and alertness.  An account of the lives of a number of victims forms the core of an extra-ordinary book, Awakenings, by Oliver Sacks.  However, before I turn to his account, a few more facts about the overall impact.

Encephalitis lethargica is characterised by fever, lethargy, delayed physical and mental responses and catatonia.  In some case victims enters a coma-like state, Parkinsonism, upper body weakness, tremors, rigidity, and even Klazomania (compulsive screaming).  Patients became frozen, their bodies and reactions stuck at the age when they were infected, even though they physically age.  Unsurprisingly, the timing of EL led to the belief it was connected to the Spanish Flu, but most modern research has argued against this.  A recent study, in 2008, concluded:  “the case against influenza [is] less decisive than currently perceived … there is little direct evidence supporting influenza having a role in the aetiology of EL”, and that “[a]lmost 100 years after the EL epidemic, its aetiology remains enigmatic.”  While opinions on the relationship of encephalitis lethargica to influenza still remain divided, the preponderance of the literature appears sceptical.

It was also unusual in another sense.  A German neurologist who examined hundreds of encephalitis lethargica patients in the 1920s, noted that their encephalitis lethargica typically evolved over time. The early symptoms would be dominated by sleepiness or wakefulness.   Then a second stage of symptoms appeared, characteristically identified by weird and unpredictable eye movements. For many the third stage would be recovery.  A 2010 Oxford University Press compendium quoted a researcher, writing in 1930, who stated, “we must confess that aetiology is still obscure, the causative agent still unknown, the pathological riddle still unsolved”, and asked, at the time of publication:  “Does the present volume solve the ‘riddle’ of EL, which … has been referred to as the greatest medical mystery of the 20th century? Unfortunately, no: but inroads are certainly made here pertaining to diagnosis, pathology, and even treatment”. In 2012, Oliver Sacks noted there was evidence a virus was the probable cause of the disease, possibly an enterovirus variant.

This ‘new illness’ was first noted in the winter of 1916–1917 in Vienna and later in some other cities.  It rapidly spread world-wide over the next three years.  The number of people infected during the ten years of the pandemic is unknown (but, as already noted, estimates suggest more than 1 million people contracted the disease, and that more than 500,000 died).  Encephalitis lethargica assumed its most virulent form between October 1918 and January 1919.  The pandemic disappeared in 1927, as abruptly and mysteriously as it first appeared, although it is likely that the Spanish Flu virus accelerated the effects of whatever caused the encephalitis or lowered resistance to it in a catastrophic way.

Finally, and equally extraordinarily, many surviving patients of the 1915–1926 pandemic eventually seemed to make a complete recovery and return to their normal lives. Despite this, the majority of survivors subsequently developed neurological or psychiatric disorders, often appearing after years or decades of seemingly perfect health. Post-encephalitic syndromes varied widely: sometimes they proceeded rapidly, leading to profound disability or death; sometimes very slowly; sometimes they progressed to a certain point and then stayed at this point for years or decades; and sometimes, following their initial onslaught, they remitted and even disappeared completely.  Often thought of as a disease of the past, it is still seen in occasional cases today.

Two flu epidemics, in 1957-8, and 1968-9, had pushed the Spanish Flu into the background by the end of the 1960’s, and encephalitic lethargica had disappeared from popular attention:  it was relegated to treatment wards.  However, it was an English doctor, then working in Mount Carmel Hospital in New York, who decided to see if he could work with some of the 200 patients in the city using a novel form of treatment.  That doctor was Oliver Sacks, then a consultant neurologist, who decided to try administering a new drug, laevo-dihydroxyphenylalanine (L-DOPA), which had proven to be a ‘miracle drug’ for Parkinson’s patients.  The results were bizarre, and Awakenings, his account of what happened, is a compelling read.  As one commentator, Frank Kermode, an English Professor at Cambridge University, described it: “this doctor’s report … is written in a prose of such beauty that you might well look in vain for its equal among living practitioners of belles lettres”.

My 1973 first edition of Awakenings is dedicated to “To the patients whose lives are here depicted”.  The title page quotes “… and now, a preternatural birth in returning to life from this sickness”.  As we discover in reading his book, for some this was a bittersweet recovery.

The patients Sacks was to meet would sit motionless and speechless all day in their chairs, totally lacking energy, impetus, initiative, motive, appetite or desire.  These ‘survivors’ had their thoughts and feelings unchangingly fixed at the point at which their long “sleep” had closed in on them during the 1920s, a time that would remain more real to them than any subsequent decade.  While their minds remained clear and unclouded, they were inaccessible.  Unable to work or see to their needs, they had been largely abandoned by their friends and families and had been put away in hospitals and nursing homes, largely forgotten.

Oliver Sacks was employed at Mount Carmel’s Beth Abraham care centre in New York’s Bronx and was given permission to experiment with the administration of L-Dopa to nearly 80 patients living there.  The result was like an explosion, or perhaps like a rollercoaster ride. Some of L-Dopa’s side-effects had a frightening intensity: in one patient’s words: “I can no more control it than I could control a spring tide. I just ride it out and wait for the storm to clear… That L-Dopa, that stuff should be given its proper name – Hell-Dopa!”

While the L-Dopa released amazing reactions, Sacks was carefully taking notes. “I cannot think back on this time without profound emotion,” he wrote later. “It was the most significant and extraordinary moment in my life, no less than in the lives of our patients. All of us at Mount Carmel [Beth Abraham] were caught up with the emotion, the excitement, with something akin to enchantment, even awe.”

In the spring of 1969, he writes: “I moved to an apartment a hundred yards from the hospital and would sometimes spend 12 or 15 hours a day with our patients – observing them, talking with them, getting them to keep notebooks, and keeping voluminous notes myself, thousands of words each day. And if I had a pen in one hand, I had a camera in the other: I was seeing such things as had never, perhaps, been seen before – and which, in all probability, would never be seen again.” It was, said Sacks, his duty and his joy “to record and bear witness”.

To read the stories of the lives of Frances D, Magda B, Rolando P, Lucy K Margaret A, George W and the others is moving, sometimes shocking and occasionally extraordinarily tragic.  As he explains, “Almost half of these patients were immersed in states of pathological ‘sleep’, virtually speechless and motionless, and requiring total nursing care; the remainder were less disabled, less dependent, less isolated, and less depressed, could look after many of their own basic needs, and maintain a modicum of personal and social life.”  The strange, almost unbelievable histories Sacks tells of the patients at Mount Carmel are exemplified in his description of  concluding moments of the life of Magda B, who had “a sudden premonition of death”.  As he describes in Awakenings, Mrs B suffered progressive blindness, a touching tic and vivid dreaming.  In other respects, her physical health was good.  Then she contacted her daughters.  “Come and see me today … there will be no tomorrow. No, I feel quite well … nothing is bothering me, but I know I shall die in my sleep tonight’.”

Sacks records that “her tone was quite sober and factual, wholly unexcited”.  The medical team wondered if they had missed something, and decided to take cardiograms, some blood tests, and other checks.  The results were ‘quite normal’.  In the evening Mrs B went round the ward, with a laughter-silencing dignity, shaking hands and saying ‘Goodbye’ to everyone there.  She went to bed,” Sacks continues, “and she died in the night.”  To reread just this one case reminded me how just what an extraordinary account Sacks provides in Awakenings.  It is full of similar moments of bizarre drama, in which you find you’re reading about strange and often disturbing events, often appearing more like moments from a fantasy novel.  But it isn’t, it is a window into yet another area of mystery concerning the human brain.

There are twenty case studies in Awakenings.  His account of Margaret A is typical, in that it describes amazing behaviour and reactions (to be clear, each case study is different in almost every respect, except for the strange ‘release’ that L-Dopa achieved), but her story proved more extreme than most.  Margaret was a New Yorker, born in 1908, the youngest child of a poor Irish Immigrant family.  In 1925, she fell ill, initially sleeping almost continually for ten weeks (apart from being woken to be fed) and fell into a state of depression.  Then she appeared to have recovered, working as a secretary and having an enjoyable social life.  However, by 1929, she began to show signs of wakefulness, put on 100 lbs in weight, had periods of depression.  She managed to keep working until 1935, and then stayed at home, nursed by her mother, but with frequent hospital visits.  In 1958, she was admitted to Mount Carmel.  From her admission onwards, her behaviour was characterised by sleepiness, depression, and excessive water consumption.  Her gait and posture were very rigid.

The initial administration of L-Dope in May 1968 seemed promising.  She could walk more easily, dress herself, and talk more easily.  Within a fortnight, she had become sociable, wanted to dance with the nurses, explained she felt a ‘star patient’, although she was having trouble sleeping.  Shortly after this, she began to develop tics, was finding it difficult to sleep, and her almost manic behaviour was alternated with ‘frozen’ periods.   By June, she started to come apart, saying of the L-Dopa, “It’s driving me mad, but I’ll die if you stop it.”

From that moment on, Sacks reported that she was almost never in a “well-modulated ‘middle’ state and has almost nothing in-between coma and hyper-vigilance”.  Sacks goes on to report that:  In the presence of excitement and perpetual contradiction, Miss A has split into a dozen Miss A’s – the drinker, the ticker, the stamper, the yeller, the swinger, the gazer, the sleeper, the wisher, the fearer, the lover, the hater, etc. – all struggling with each other to ‘possess’ her behaviour.  Her  real interests and activities have practically vanished, and have been replaced by absurd stereotypies, continually ground smaller in the mill of her being.  She is completely reduced, for most of the time, to a ‘repertoire’ of a few dozen thoughts and impulsions, increasingly fixed in phrase and form, and repeated, compulsively, again and again.  The original Miss A – so engaging and bright – has been dispossessed  by a host of crude, degenerate sub-selves – a schizophrenic fission of her once-unified self”

This case study ends with another quite unsettling section.  We learnt that she has a younger sister, who arrived once a month to take her out.  They would go on excursions, eat out, and have a great time.  In the book the sister explains they had a wonderful day, each time, and adds “She talked and laughed the way she used to in the old days, back in the twenties before she got ill … she goes mad in your madhouse because she is shut off from life.”  What are we to make of this – and all the other cases Sacks describes.

Perhaps it is unfair to focus on this particular case as an example.  Many of the other patients Sacks treated had equally bizarre reactions to L-Dopa, but in several cases the drug was to help them get back to a more viable way of life.  Some were able to go back to work, marry, have children, and lead fairly normal lives.  If Margaret A offers a sad, unresolved and ultimately unsatisfactory account, in almost every case the original Encephalitis Lethargica and the subsequent impact of L-Dopa left the individuals with scars of one kind or another, in some cases physical consequences, and for almost everyone psychological concerns and uncertainties.

However, Awakenings gives us something more.  It was superbly written, a presentiment of the several books Oliver Sacks went on to author.  His reflections on health, recovery and change take up the last 50 pages of Awakenings, in three sections, under the heading of  Perspectives.  The first part reflects on the process of Awakening and how it was experienced by his patients.  The second is on the topic of Tribulation (and many had extraordinary journeys following that “flash-like drug-awakening of the Summer of 1969” ).  Finally Sacks explores the varieties of  Accommodation, and the very different responses from a return to an almost normal life through to some scarcely doing much more than surviving.

Given his mesmerising and occasionally dark account, any final comments have to come from Oliver Sacks.  In 1982, he wrote:  “I have become much more optimistic than I was when I […] wrote Awakenings,for there has been a significant number of patients who, following the vicissitudes of their first years on L-DOPA, came to do – and still do – extremely well. Such patients have undergone an enduring awakening, and enjoy possibilities of life which had been impossible, unthinkable, before the coming of L-DOPA”.

Transitions

I first read about ‘rites de passage’ back in the 1960s.  I was a student, enrolled in a social anthropology course, and Arnold van Gennep’s book Les Rites de Passage was listed.  It had appeared in an English translation back in 1960.  A key text, it described the process through which a person or a group goes through a change in social status.  Van Gennep explained that rites of passage have three phases: separation, liminality, and incorporation.

In the first phase, people are withdrawn from their current status and prepared for the move from one social status to another. “The first phase (of separation) comprises symbolic behaviour signifying the detachment of the individual or group … from an earlier fixed to point in the social structure.”  There is often a detachment or ‘cutting away’ from the former self in this phase, which is signified in symbolic actions and rituals. One of the examples Van Gennep uses is the cutting of the hair for a person who has just joined the army.  He or she is ‘cutting away’ the former self:  the civilian.

The transition (liminal) phase is the period between stages, during which one has left one place or state but has not yet entered or joined the next.  “The attributes of liminality or of liminal personae (“threshold people”) are necessarily ambiguous.”  I’m not sure why this example came to me, but this is a bridegroom on a stag night or bride at a ‘hen do’.  This is a sanctioned time when misbehaviour is permitted – even encouraged.

In the third phase (reaggregation or incorporation) the passage is “consummated [by] the ritual subject”.   Having completed the rite and assumed their ‘new’ identity, the individual re-enters society with anew status. Re-incorporation is characterized by elaborate rituals and ceremonies, like debutant balls and college graduation, and by outward symbols of new ties: thus “in rites of incorporation there is widespread use of the ‘sacred bond, the ‘sacred cord’, the knot, and of analogous forms such as the belt, the ring, the bracelet and the crown.”

Anthropologists like to observe these rites de passage in societies, as they are often insightful:  they demonstrate the markers of social status, and the symbolism is a guide to other rituals in behaviour, both on special occasions and in more mundane activities.   This perspective received considerable impetus with the development of the sociological theory of symbolic interaction, peoples’ use of shared language and rituals to create and reinforce symbols and meaning.  It’s a frame of reference that helps us better understand how individuals interact with one another through symbolic worlds, worlds that shape individual behaviour.  For theorists symbolic interactionism was a framework that helped understand how society is preserved and created through repeated interactions between individuals. It is the shared understanding and interpretations of meaning that shape many of the significant interactions we see between individuals. Individuals act on the premise of a shared understanding of meaning within their social context.  People live in both natural and symbolic environments.

I wasn’t a sociologist, but I was interested in this perspective.  However, that interest grew significantly once I met Anselm Strauss .  Anselm was a short, slightly overweight and quietly spoken man, a professor of sociology at the University of California Medical Center in San Francisco.  I think the best word to describe him was gentle.  He loved music, played the piano at home, and had a fascination with kinetic sculptures.  From when I first met him at the end of the 1960s, I realised he was the teacher I aspired to be, never lecturing but always asking questions, and by that means revealing understanding and insight.  He set a standard for how to be a university professor that remained my goal for the years I worked in academic institutions, a standard I longed to meet, but one which was always just beyond my grasp.  If you think about it, that’s always the best thing to aim for, something that is almost there, encouraging to strive to be better.

Perhaps there is no better way to explain what he was like than to quote from the introduction from an Anselm Strauss’ festschrift, written by Roberta Lessor in 2000 (in a supplement to Sociological Perspectives):

Anselm Strauss was the most unpretentious academic I have ever known. In his nearly sixty years of working and publishing, Strauss advanced symbolic interactionist theory and method remarkably, yet he was soft-spoken and unassuming. His dress and demeanor mirrored his personality. He preferred open-collared shirts and his trademark pullover sweaters to coats and ties, and he was even known to carry drafts of whatever he happened to be working on in a plastic bag—much lighter and easier on the back than a briefcase. He lived most of his life with chronic illness and worked the small necessities of self-care into his daily routine. Totally the sociologist, he used his experiences both in and out of the hospital as data, observations of “medical work” from which he could draw insights. This was a life lesson I took from Anselm: observe what life hands you as data for a sociological analysis. It makes life more interesting, you may improve your analytic skills, and it may even help your situation. Sometimes Anselm needed to take a short rest, and if he were working with students in a seminar, he would give a characteristic, almost dismissive, small wave of his hand and say, “just go on, I’ll be right back.” That might mean his reclining on the bench beside the fireplace in the Third Avenue Victorian (which housed the sociology program) while we went on with our seminar for twenty minutes. Or it might mean his closing his eyes as he sat in his chair, to return to the conversation in a few minutes with a smile and his full attention.

I had first met Anselm on one his early visits to the UK.  Initially I saw him as some variety of kind uncle, enquiring about what I was doing.  As he would draw me out, wondering about why I had mentioned something, querying what I meant by the words I used, initially I didn’t ‘get it’.  It took some time before I realised how extraordinarily effective he was as a teacher.  Indeed, he was never a ‘teacher’, but rather a friend on a journey, who appeared to know something about the territory, and would every so often point out a possibly worthwhile detour, or a reason to stope, reflect and reconsider.  At my first acquaintance, I didn’t realise he was a wonderful guide:  I suspect I imagined that, back in the US, he gave lectures like everyone else did.  It took a visit to see him in beloved San Francisco for me to understand how he was helping me learn.

He also wrote several insightful books.  Time for Dying is one of these (it was preceded by Awareness of Dying).  As he explained in the preface, he and co-author Barney Glaser (a researcher in the department) saw the book as directed to two audiences.  ‘Because we wish to contribute toward making the management of dying – by health professionals, families and patients – more rational and compassionate, we have written this book, first of all for those who must work with and give care to the dying.”  The second audience was social scientists, a contribution to exploring the “temporal aspects of work”, a group  that included those with interests in many areas, some far from interested in health care and hospitals.

Time for Dying was published in 1968.  My copy is hand dated 1971.  Reading it more than fifty years later was a shock:  not because it wasn’t the book I had thought it to be, but because its underlying approach has become so firmly embedded in the way I have worked.  Anselm Strauss described his approach as ‘grounded theory’ in a book published a year earlier (The Discovery of Grounded Theory, also written by Strauss and Glaser).  They made it clear they had had several goals in mind when writing about their approach to developing theory.  They wanted to:

• to legitimise qualitative research;
• to criticise the functionalist school in sociology;
• to demonstrate the possibility of building theories from the data, instead of choosing to rely on ‘ethnographic’ description (what a man from Mars would see).

My copy of Time for Dying still has the original paper wrapper cover – which shows eight people, all in medical whites, standing together and clearly discussing a case.  At the bottom of the cover we read the book is “a detailed analysis of the reciprocal effects of patients, staff, and institutional structure in the management of terminal patients in institutions”.  The Introduction makes it clear that the book was written ‘first of all’ for people who have work with and give care to individuals who are dying.  It notes that in 1963 53% of all death in the US were in hospitals and nursing homes.  I suspect the figures are higher today:  a 2019 Australian study found 51% of deaths were in a hospital/medical service area, and 29.5% in residential aged care facilities (although this is a wider category than nursing homes.  This is, of course, an indicator of how far death is managed ‘out of sight’, with a little under 15% taking place at home.  As the Introduction made clear (and must be even more the case today), “outsiders to the family have been delegated responsibility for taking care of dying during their last days or hours”.

Time for Dying focusses on the ‘temporal features of terminal care’.  It is an important perspective, as we often are encouraged to think about the psychological or ethical aspects of behaviour towards a dying individual.  However, they want to remind us that this is also about ‘work’, both routine, around meals, drug administration and the like, and the less predictable, including tests, interventions and responses.  It is a complex work management process, especially as many patients approaching death may be heavily drugged, temporarily comatose or even unconscious, and typically having little conversational interaction with the staff.  Inevitably, while many staff may be involved when there are critical incidents occurring, for much of the time attention is limited and relies on impersonal monitors as much as on staff observation.

As Glaser and Strauss point out in their Preface, “the training of physicians and nurses equips them principally for the technical aspects of dealing with illness.  Medical students learn not to kill patients through error, and to save lives through diagnosis and treatment.  But their teachers put little of no emphasis on how to talk with dying patients; how – whether – to disclose an impending death; or even how to approach the subject with wives, husbands, children and parents of the dying”.

In 1971, I arrived at the University of Edinburgh, where one of my interests was looking at ways in which the social and behavioural sciences could be introduced into the medical school curriculum.  The two books on dying had made an impact on me, although not just in relation to the dying:  as I saw it, medical students needed a better appreciation of sociology and psychology to be able to fulfill their roles effectively.  I continued to look at ways to enhance student understanding of these issues for the next ten years, in Scotland and then in Australia.

Fifty years later, an appreciation of the social sciences is now a standard part of the medical school curriculum, and nurses and doctors are much better prepared to deal with the families and friends of patients.  Inevitably, some will be more able to deal with social and psychological issues than others.  Individual differences will always be evident.

When my wife was dying some years ago, the contrast between her two principal doctors was vivid.  Her medical oncologist was open and helpful as he explained progress, and later the lack of progress to me and my children.  He explained his strategies, and his enthusiasm for measures, his warmth, and his devotion was evident.  So was his distraught appearance as it became clear that the measures he was trying were failing.  His colleague, the surgical oncologist, was clear, direct, and basically impersonal.  It was only after an unexpectedly long surgery, that the other side of his character emerged:  he was tired, frustrated, and – although he couldn’t bring himself to say it – defeated.  He knew the prognosis was bad, but he couldn’t find the words to explain.  He left that to his colleague.  To be clear, I don’t mean to imply any criticism:  both dealt with what they knew and communicated well, but their approaches were a reflection of personalities that were intrinsic.

That time illustrated an important lesson about transitions.  Van Gennep was an astute observer of rites de passage.  However, describing social process and symbols is an account that is essentially de-personalised.  It is concerned with identifying the underlying ways in which we manage changes in social status.  It influences the way the ‘work’ is executed.  However, at the level of specific transitions, variation is enormous.  In that sense, ‘real’ status passage in a task that involves many participants, each one of whom contributes to shape the process.  Perhaps I can best explain that by example.

Marriage is a very important kind of status change.  While occasionally the bride and groom might feel it is all about them, they are one, albeit important, part of a complex process of negotiation.  In addition to the couple, others who take part, and often have important parts to play as well as very real interest in the outcome, can include parents, other family members, friends, colleagues, officers (whether priests or delegated officials), not to mention musicians, choirs, caterers, waiting staff, and so on.  In some cases, the cast can be hundreds!

I have managed to get married three times.  On the first occasion, it was essentially a ‘family’ business, with several family members on both sides.  The next time, it was a tiny group, little more than my wife and I, a few members of her family, one child, and a few others.  The third time around, it was largely an event for friends.  Each time around, it was a time of transition:  a brief interlude before becoming a married couple.  However, the symbolism, the process, and the participation of others varied enormously.  To return to Anselm Strauss, he would observe that this is a matter of ‘work’.  People have roles and tasks, for a short-term project.  There is a clear outcome, and certain rules that shape the way the work is undertaken.  But each marriage was undertaken in its particular way.

Strauss and Glaser on dying describe this feature of status passage brilliantly.  The two books, and especially Time for Dying, capture both the characteristics of the underlying process, while carefully noting variations and unpredictable alternatives.  However, as is also true of some other major rites de passage, success is determined by all the participants in the process feeling ‘it was done right’, respecting the unique elements of the event, while also knowing that the appropriate social proprieties were respect.  We are all involved in social transitions, and we want to feel good about how they were accomplished.

Peter Singer

Just about every day an expert is happily giving the rest of us advice on what we need to do.  The proposal is often embedded in pieces of persuasive writing, leaving us with two challenges: first, which of all the various suggestions on offer should we follow; and second, how can we be certain they are the right or the best things to do?  When it comes to ethical issues, I like logic.  I believe actions should be based on clear analysis rather than persuasive writing, but it must be a justifiable analysis too.  It’s for this reason I often return to Peter Singer, who makes his reasoning clear, and even when I disagree with him, as I do on some issues, I have to do so by responding the logic of his position.  However, before turning to some of Peter Singer’s views, two recent examples of advice illustrate how easy it is to be swept along by propositions that rest on troublesome, even contestable assumptions.

Oxford philosophers William MacAskill and Toby Ord, from the university’s Future of Humanity Institute, coined the word ‘longtermism’ several years ago. Their approach is based on utilitarian thinking about morality.  According to utilitarianism, famously advocated by Jeremy Bentham and John Stuart Mill in the nineteenth century, we should act in a way that  maximises overall, aggregate well-being, adding points for every extra moment of happiness, and subtracting them for suffering, taking account of probability as we do so.  The maths of long-termism can become astonishing:  if we assume humans will survive for a million years, and even with a smaller average global population, there could be at least 8 trillion humans yet to be born.  Imagine this choice:  save a million lives today or shave 0.0001 percent off the probability of premature human extinction, a one in a million chance of saving at least 8 trillion lives, the utilitarian logic is you should do the latter, and allow a million people to die.

Really!  Utilitarianism is fundamentally impersonal.  It is based on the principle we cannot give more weight to our own interests or the interests of those we love than to the interests of perfect strangers. In other words, we must make sacrifices for the greater good.  Worse, it suggests we should do so by any effective means.  Using those earlier statistics, MacAskill states that if we can shave 0.0001 percent off the probability of human extinction by killing a million people, we should.  The moral mathematics of aggregate well-being may not be the whole of ethics, but altruism plays a part.  When asked what we should do to benefit others over the long term, he points out those in the future may vastly outnumber those who occupy the present, and, uncomfortably, we should accept their very existence depends on us.  Yes, that is extreme but is only about logic?  What about priority between various alternatives?

MacAskill and Ord helped establish Giving What We Can, which encourages people to pledge at least 10 percent of their income to charitable causes. With our tithe, they argue, we should be utilitarian, aggregating benefits, subtracting harms, and weighing odds.  Our ten percent should be directed to the most effective charities, assessed by impersonal empirical measures, Effective Altruists argue.  MacAskill a leading figure, Peter Singer is another.

Effective Altruists don’t need to be utilitarians about morality (although many are), and they do respect the rights of others.  However, some are like MacAskill in being determined quantifiers.  Their altruistic calculations can lead to long termism and to fairly radical arguments about future generations. “Future people count,” MacAskill writes, “There could be a lot of them.  We can make their lives go better.  This is the case for longtermism in a nutshell.  The premises are simple, and I don’t think they’re particularly controversial.  Yet taking them seriously amounts to a moral revolution.”

The utilitarian logic is clear. Most people concerned with the effects of climate change would accept we should act to maximise well-being.  Yet MacAskill pursues this logic to unexpected ends, offering uncompromising views.  As of 2022, the Doomsday Clock, which measures our proximity to doom, was set at 100 seconds to midnight, the closest it’s ever been. Despite this, according to a study commissioned by MacAskill, even in the worst-case, a nuclear war that kills 99 percent of us, society would probably survive. The future trillions would be safe. The same goes for climate change. MacAskill is upbeat about humanity’s  chances of surviving seven degrees of warming or worse: “even with fifteen degrees of warming,” he contends, “the heat would not pass lethal limits for crops in most regions.”

When I read this, I was stunned.  First, it conflicts with almost everything else I’ve read. The last time the temperature was six degrees higher than preindustrial levels was 250 million years ago, at the time of the Permian-Triassic Extinction, the most devastating of the five great extinctions.  This was when deserts reached almost to the Arctic, and more than 90 percent of species were wiped out.  Environmental journalist Mark Lynas summarises current research:  “at six degrees of warming the oceans will become anoxic, killing most marine life, and they’ll begin to release methane hydrate, which is flammable at concentrations of five percent, creating a risk of roving firestorms” (in Our Final Warning: Six Degrees of Climate Emergency, 2020).  How we could survive this, let alone fifteen degrees hotter than now?

More to the point is how MacAskill values survival in the long term over a decrease of suffering and death in the near future.  “Most of us agree that (1) world peace is better than (2) the death of 99 percent of the world’s population, which is better in turn than (3) human extinction. But how much better? Where many would see a greater gap between (1) and (2) than between (2) and (3), the longtermist disagrees. The gap between (1) and (2) is a temporary loss of population from which we will (or at least may) bounce back; the gap between (2) and (3) is ‘trillions upon trillions of people who would otherwise have been born.’” (this from Kieran Setiya’s recent review of MacAskill’s book in the Boston Globe).

I understand the maths, but I simply can’t accept it.  I can’t sacrifice people now for the sake of trillions in the distant future because, as far as I am concerned, the long-term future is both uncertain and unknowable, while the challenges for people now are evident and pressing.  I have always remembered and agreed with Carol Gilligan’s comment in In a Different Voice, “I have a very strong sense of being responsible to the world, that I can’t just live for my enjoyment, but just the fact of being in the world gives me an obligation to do what I can to make the world a better place to live in, no matter how small a scale that may be on.”

Nor can I get overly excited about some other proposals.  Gaia Vince is a freelance British environmental journalist, broadcaster and non-fiction author.  She tells us a great upheaval is coming.  Climate-driven movement of people will add to a massive migration already under way to the world’s cities.  The number of migrants has doubled globally over the past decade, and the issue of what to do about rapidly increasing populations of displaced people will only become greater and more urgent. To survive climate breakdown will require a planned and deliberate migration of a kind humanity has never before undertaken.

She suggests how we manage this global crisis, and how humanely we treat each other as we migrate will be key to whether this century of upheaval proceeds smoothly or with violent conflict and unnecessary deaths.  “Managed right, this upheaval could lead to a new global commonwealth of humanity.  Migration is our way out of this crisis.  Climate change is in most cases survivable; it is our border policies that will kill people. Human movement on a scale never before seen will dominate this century.  It could be a catastrophe or, managed well, it could be our salvation.”  She may be right, but is migration the only answer?

Why am I concerned about MacAskill and Vince?  It’s not because of the issues they discuss.  It’s their confidence in offering solutions.  I don’t believe there are ‘solutions’, only strategies to help us move forward.  Unlike solutions, strategies are approaches to be adopted, and unlike solutions, they are always tentative and under review.  In contrast to these two, people like Peter Singer focus on immediate problems and their consequences, rather than positing longer-term solutions to distant issues.  He recognises it is much ‘easier’ to develop solutions for the long run, but doing so skates over the shorter-term, pressing issues these ignore.

Peter Singer has written several important books about living an ethical life.  People who do this “adopt – to use Henry Sidgwick’s memorable phrase – ‘the point of view of the universe’.  This is not a phrase to be taken literally, for unless we are pantheists, the universe itself cannot have a point of view at all.  I shall use Sidgwick’s phrase to refer to a point of view that is maximally all-embracing, while not attributing any kind of consciousness or other attitudes to the universe, or any part of it that is not a sentient being.  From this perspective, we can see that our own sufferings and pleasures are very like the sufferings and pleasures of others; and that there is no reason to give less consideration to the sufferings of others, just because they are ‘other’.  This remains true in whatever way ‘otherness’ is defined, as long as the capacity for suffering or pleasure remains.”

Singer is well aware that people who take on the point of view of the universe can be daunted by the size of the task that faces them.  Many issues pose uncertainties about how to go about achieving their objectives, and how far to pursue them.  There are no easy answers, no ‘final’ solutions, but ongoing debate and analysis while remaining aware of change and uncertainty.  As Singer says “we are part of this world and there is a desperate need to do something now about the conditions in which people live and die, and to avoid both social and ecological disaster.  There is no time to focus our thoughts on the possibility of a distant utopian future … We have to take the first step.  We must reinstate the idea of living an ethical life as a realistic and viable alternative to the present dominance of materialist self-interest.”

Singer is also tough minded, and his analyses are often uncompromising.  To take one example from Practical Ethics (1991), he considered the ethical issues in infanticide: “Infants are sentient beings who are neither rational nor self-conscious.  So, if we turn to consider the infants in themselves, independently of the attitudes of their parents, since their species is not relevant to their moral status, the principles that govern the wrongness of killing non-human animals who are sentient but not rational or self-conscious must apply here too …  the most plausible arguments for attributing a right to life to a being apply only if there is some awareness of oneself as a being existing over time, or as a continuing mental self.  Nor can respect for autonomy apply where there is no capacity for autonomy. …   So, the issue of ending life for disabled newborn infants is not without complications, which we do not have the space to discuss adequately.  Nevertheless, the main point is clear: killing a disabled infant is not morally equivalent to killing a person.  Very often it is not wrong at all.”

This might be somewhat less controversial than when he wrote 30 years ago.  Singer writes carefully and clearly about euthanasia.:  “Infanticide includes considering justifiable killing for beings who have never been capable of choosing to live or die.  Ending a life without consent may also be examined in the case of those who were once capable of choosing to live or die, but now, through accident or old age, have permanently lost this capacity, and did not, prior to losing it, express any views about whether they wished to go on living in such circumstances.”  In 1991 Singer gave the example of Rita Greene, a hospital patient in Washington for thirty-nine years without knowing it. She’d been in a vegetative state since undergoing open heart surgery in 1952.  Today, most hospitals have procedures to follow to end support for people like Rita Greene if it’s clear they are beyond resuscitation, that they have no experiences at all and can never have any again.  Singer suggests, “Their life’s journey has come to an end. They are biologically alive, but not biographically.”

It becomes more challenging when we move on to voluntary euthanasia.  Less the case now than when Singer was writing Practical Ethics, many existing laws back then had the effect that people suffering unrelievable pain or distress from an incurable illness and who begged their doctors to end their lives were asking their doctors to risk a murder charge.  Advocates of voluntary euthanasia wanted any laws of this kind changed so doctors can legally act on patients’ desire to die without further suffering.  They can do this in several countries today, as long as they comply with certain conditions. Singer points out the case for voluntary euthanasia has some common ground with the case for non-voluntary euthanasia: death is a benefit for the one killed.  They differ, however, in that voluntary euthanasia involves the killing of a rational and self-conscious person and not a merely conscious being.  Are the ethical issues different when the ‘being’ is capable of consenting, and does consent?

Singer is blunt and clear.  Suppose a person suffering from a painful and incurable disease wishes to die.  First, killing takes place only with the genuine consent of the person;  if we do not wish to be killed, we simply do not consent, but if voluntary euthanasia is prohibited, we may fear that our death will be needlessly drawn out and distressing.  Second what about the ‘right to life’?  He points out  an essential feature of a right that we can waive our rights if we so choose.  “I may have a right to privacy; but I can, if I wish, film every detail of my daily life and invite the neighbours to my home movies.  Neighbours sufficiently intrigued to accept my invitation could do so without violating my right to privacy, since the right has on this occasion been waived.  Similarly, to say that I have a right to life is not to say that it would be wrong for my doctor to end my life if she does so at my request.  In making this request I waive my right to life.”  Finally, respect for autonomy means we should allow rational agents to live their own lives according to their own choices, free from interference or coercion.  If rational agents choose to die, then we should allow them to do as they choose.

Singer is an unashamed rationalist.  There are other objections to infanticide and euthanasia, as well as cultural and religious beliefs, and he acknowledges departing from the traditional sanctity-of-life ethic carries a very small but real risk of unwanted consequences.  Against this he argues we must balance the harm to which the traditional ethic gives rise, harm to those whose misery is needlessly prolonged.  His views deserve respect, even if we disagree.

As I was finishing these comments I read about Happy, an elephant in New York’s Bronx Zoo.  Elephants are social, family-oriented and clearly intelligent animals, with large brains.  Their mental capability has been shown in many studies, including Happy demonstrating her ability to recognise herself in a mirror.  However, living in her zoo enclosure Happy’s life has been one of effective solitary confinement for several years.  Singer would argue Happy is a ‘rational and conscious person’ with a right to live freely.  Incarcerated, we are infringing on her rights, and she deserves to be released to enjoy a social life with other elephants.  We are cruel to animals in solitary captivity like Happy, just as we are cruel to impose life on people who wish to put an end to an existence dominated by extreme and untreatable pain.  In both cases, what gives us the right to be cruel gods?  Certainly not a defendable logic.

Here and there – India

We’re looking at a village somewhere in India.  A young man is entering a compound.  He is missing part of one leg, and he’s using a crutch:  it must have been a while ago, as he’s very adept.  As he enters, it becomes clear that this is a rural medical centre, and it appears to be rather basic.  What is not clear if this young man was expected, but we see him speaking to an older man, and there’s an assistant there, a woman, who is asking him questions.  Now he goes into one of the wooden huts, and we have to wait.  Time passes, and it is something like 3 hours later when he finally emerges.  As he comes out, we can see he now has an artificial leg attached, and he’s walking carefully.  As he picks up confidence, he walks a little quicker.  He goes around the compound, and within a few minutes he’s running.   He must have been expected to be there for a fitting, and it seems to have gone well, very well indeed.

Let’s step back.  We have just been watching a video, commissioned by C K Prahalad, and we need to fill in a few more details.  What we have just seen wasn’t a fitting for an artificial leg that had been modified over a number of visits, but this was a one-time exercise.  It seems hard to believe, but that young man had never been to the clinic before.  He lived hours away.  After arriving, and in the course of a morning he had been provided with an artificial limb, and was able to use it, even to run, in just a few hours.  Before you think ‘Gosh, he was lucky’, he is one of thousands who have had the same experience, lives transformed in just a few hours.  And yes, before you add ‘It must have been expensive’, it wasn’t. This is in rural India, in what in Australia we might call a bush clinic, offering services at ‘bush prices’.

For business school students over the last two decades of the 20^th Century, C K Prahalad and Gary Hamel were generally regarded as two great thought leaders in strategy and innovation (along with a few others).  Their book, Competing for the Future, remains a classic, and their 1990 Harvard Business Review article, The Core Competence of the Organisation, is still one of the journals most cited papers thirty years later.  A ‘core competence’ is an organisational capability, something in which a business excels, through which it performs better than the competitors, and which drives the business’s competitive advantage and success.  The concept remains one of the central ideas in helping enterprises develop business strategy.  When I used to teach in a business school, Prahald was one of the (few) people whose books I encouraged returning businesspeople to read, and he was a key figure in the field.  Organisational capabilities and the nurturing of key strategic competencies remain important in business today, even if the pace of digital transformation can see an advantage one year surpassed and superseded the next.

However, beyond MBA courses on strategy, it was another of his books that I found even more important, one that has been part of my personal set of recommendations ever since I first read it.  That book was The Fortune at the Bottom of the Pyramid; it is subtitled Eradicating Poverty through Profits.  Prahalad’s approach was simple.  Companies make things and provide services.  However, most of their customers live in the more affluent parts of the world.  What he wanted his readers to understand was that if you work at it, you can find ways to harness the power of corporations to deliver what is needed for those less well off, those who comprise 80% of the world’s population, the people at the ‘bottom of the pyramid’ and yet still made profits for the business and an excellent return for shareholders.

Among many examples, one of the most telling was an initiative by Hindustani Lever Limited, part of the Unilever group. At the end of the 20^th Century, most Indians still lived in under-resourced areas, away from the cities.  These were home to more than three quarters of the population, and the figure is probably similar today.  Surviving on very low incomes with poor diets and a compromised environment, health was a major challenge.  Without adequate medical facilities, even simple illnesses like diarrhea could have a devastating effect, and infant mortality was high.  One factor that made a big impact was hygiene, and the Indian Government constantly sought ways to introduce and sustain better practice.

The government developed a Public Private Partnership (PPP), and Hindustani Lever joined with government agencies and marketing specialists to get soap to rural families.  Inability to clean hands was the dominant issue; clearly, the regular use of soap would make a significant difference.  The story has many aspects, but one element illustrates Prahalad’s approach.  Traditionally, soap had been seen as an expensive beauty product.  Hindustani Lever took up the challenge, and reformulated their Lifebuoy brand, adding an antibacterial agent, and changing the manufacturing process to produce a cheaper, denser, smaller, and longer lasting bar.  They changed the additives to a more neutral aroma.  The result was a far more affordable soap, easy to distribute, and although the profit per bar was tiny, sold in large quantities it would cover all the manufacturing, marketing, and distribution costs, and still make a small but adequate profit for the company.

It was at this point that the partnership with government and rural agencies became important.  Promoting soap, which required selling it as a health benefit rather than a beauty product, and promoting the concept to tiny villages, required a major rethink.  Marketing had to be simple and cheap, using locals to explain the benefits.  Distribution was based on how goods were traded across large areas with small numbers, and the central role women played as traders (especially in rice, the main rural product).  To Hindustani Lever’s credit, they were willing to rethink every element of the business they knew for this new context.  The results have been impressive.  Slowly, health outcomes in rural India have been improving.

While Prahalad had looked to a major company in developing access to soap, he was also interested in other successful endeavours undertaken at the ‘micro’ level.  One of these was Jaipur Foot, whose activities were the subject of the video. Loss of a lower limb or foot is a common and extremely disabling event affecting some 25m or more people worldwide, and at least 5m in India.  For those at the bottom of the pyramid, it can mean that work is even more difficult to obtain, and managing everyday life becomes hazardous.  Prosthetic feet and lower limbs have been available for a long time, but they are expensive.  When I looked at this a couple of decades ago, the price for a prosthetic in the US ranged between $10,000 and $50,000; fitting was an expensive process, and on top of that, most prosthetics only lasted 3-5 years of normal wear and tear.  A completely prohibitive price and not an option for the poor.

It wasn’t just cost.  Ram Chandra Sharma was a sculptor and engineer who could see that those Indians who did manage to get fitted with one of the existing artificial lower limbs or feet faced problems.  Prosthetics were designed for use by Westerners, whose lives were very different from those of rural Indians.  What was needed in India was an artificial limb that responded to four distinctive needs:  squatting (rather than sitting in a chair); sitting on the ground cross legged; walking on uneven ground, both dry and wet (when working in paddy fields); and walking barefoot.

With Dr P K Sethi, an orthopedic surgeon, Sharma set about designing an alternative and much cheaper artificial limb that would meet Indian needs.  The eventual design of the Jaipur Foot used many simple components such as PVC piping, wood, sponge rubber and vulcanized rubber (he got that last idea from looking at car tyres).  He also worked to streamline fitting, so that an amputee could have a Jaipur Foot in place and usable with just one visit to a clinic.  The cost of the raw materials was just $12.54, and the total cost, including fitting, was $30.   As the video showed, the idea worked brilliantly.

I thought about the Jaipur Foot story when I was running some training courses in India.  The company was Cisco, and it had a huge operation in Bangalore.  My workshops were to be held in the Cisco Campus in Bengaluru (or Bangalore as I knew it).  The journey to the campus was almost bizarre.  I arrived at the overcrowded and old airport, left in a taxi, and set off for Cisco Building 25 (I guess they number their buildings all over the world, just as they do in San Jose!).  The road out of the airport was fine, but soon it became busy, then very busy, with little sign of anyone following the equivalent of a highway code.  Finally, it deteriorated even further into nothing more than an extremely uneven dirt road, with potholes and the remains of what might have been a concrete section.  Suddenly, the taxis drew up at a tall security gate.  I was checked in, and once through, almost magically I found myself in compound with modern buildings, walkways, and lawns, and, I soon discovered, snack bars and a restaurant.  It was the closest I have come to leaving this world and entering another!

That enclosed campus, in what is now known as Embassy Tech Village, was a physical reminder of the reality of India.  As I’ve already mentioned, back in the 1990s more than 80% of Indians lived in poverty, many in rural areas, but millions in the slums of the major cities.  The remainder, above the poverty line, were further divided, with only a small percentage receiving incomes like those received by citizens in most post-industrial countries.  However, there was another important factor here:  India was far behind in developing its manufacturing economy, relying on a services sector, significantly driven by IT support.

Inside that compound, I was in that tiny part of India that drove its economy and employed a very small percentage of its people.  It was almost like an upside-down version of Australia.  Australia has a large percentage of its population living well above the poverty line, and doing so in enjoyable surroundings, with a relatively small, often invisible part of the population living in poverty, many of whom are its Aboriginal People.  India had, and still has, a large percentage of its people living well below the poverty line, and doing so in appalling situations, with a small, almost invisible part of the country living wealthy lifestyles, and many of these the well-educated working in the IT sector.

In that brief visit to Bangalore, I saw the challenge C K Prahalad was trying to address in asking companies to rethink what they did to make goods and services available to people living with woefully limited resources.  The Fortune at the Bottom of the Pyramid puts a positive spin on an almost overwhelming challenge.  In the next couple of years, India will reach a total population around 1.38bn, about the same as China:  China’s population has stopped growing, but India’s will continue to get larger, and will surpass China somewhere around 2024, and is expected to reach 1.7 bn in 2050.

If the size of the problem were not enough, party politics is aggravating the issues, as the BJP quietly, or occasionally overtly and aggressively, pushes its divisive policies to support Hindus at the expense of Muslims, in a country with 200 m Muslims.  A giant population resting on a huge powder keg of religious tension:  It’s a miracle there haven’t been more than the occasional riots that have taken place in recent years, following the major riots that took place in 1992 in Bombay and in Gujarat in 2002, where some 1,000 and 2,000 were killed respectively, mainly Muslims.  Most recently, there have been riots in Northeast Delhi with multiple waves of bloodshed, property destruction, and rioting, beginning on 23 February 2020 and caused chiefly by Hindu mobs attacking Muslims.  Of the 53 people killed, two-thirds were Muslims who were shot, slashed with repeated blows, or set on fire.

Would I have known anything about these destructive religious tensions inside the calm Cisco campus, running a program for very smart engineers on radical innovation?  Of course not.  Part of the privilege enjoyed by affluent Hindus is to be insulated from the poor, and poor Muslims in particular.  Indeed, until recently while they might have known about major riots and violence, they could have remained unaware of the everyday incidents in the slums or away from the cities, possibly even not even knowing many such events were happening.

What has changed is access to information.  Digitisation and the internet have completely reshaped our world and what we know about it.  You can find out about social entrepreneurs helping disadvantaged groups.  You can discover the emergence of new techniques to make products and services available to millions for the first time.  You can read about violence and tribal behaviour in the India subcontinent, in Africa, in Asia and in Europe.  You can explore trends and changes in politics, economics, business, the arts, sport, whatever topic you want, on any aspect you can imagine.  You can hear about everyday riots in city slums.

Were I to go to Bangalore today, travelling through its wonderful new airport, not only would it look very different from the shambolic city I saw before, but I would have access to guides, information, suggested itineraries, themes to explore, explanations of religious iconography, symbolism and Hindu and Muslim holidays and traditions, even where to go to experience a variety of cuisines, let alone lists of museums, temples, shrines and mosques to explore.

All of that makes it clear there is the problem.  Is there a business like Jaipur Foot I could go and study?  There are thousands.  I might want to look at how industries from motor car manufacturing to telephony have been transformed, and the hundreds of strategies being implemented in rural India to improve the health, food and the broader environment in which poor villagers live.  I could spend a year chasing up fascinating issues, and just as much time reading about them.  At the end of all that, more will have changed, more will be available, and my ignorance will remain substantial in the face of so much change unfolding.  I would like to know more about Bollywood, and how that film industry is changing.  I’d like to find the ‘Peter Singer’ of Kolkata and understand how he or she sees awareness of people and their needs developing.  I’d like to visit one of the outsourced medical diagnostic centres in Mumbai and see how Indian IT experts are developing better and better diagnostics systems to analyses the millions of scans sent there from North America.

The availability of information is such that India is beyond my reach, beyond that of most outsiders, and probably beyond Indian governments at the national and provincial levels.  Indeed, I suspect the only way for most people to navigate a meaningful life in the 21^st Century is to keep ignoring things.  Just concentrate on a few news sources, follow a few blogs and commentaries, read books, both fiction and non-fiction, and remember to carve out time everyday where you are not paying attention to what is going on (I hide in the world of music, classical, often baroque, but romantic and modern, too).  Apart from that, spend time on relationships, talking with family and friends, regularly.  Relationships are what really matters.  What did Kenneth Gergen suggest in last week’s blog?  He reminded us we become who we are through our interaction with others: “we sense ourselves as both constituted by, and constituting, the other”.  Hermits make for great stories and cartoons, but in real life we are nothing without having people around us.  Easy to do if we are talking about family and friends, but how can I keep in touch with the wider world, with life in India today?

Here and There – Finland

In a way I hadn’t anticipated, I found writing about Finland was also an exercise in writing about memory.  I have often wondered if some memories disappear because they are associated with moments we would rather forget.  Not really embarrassing moments, they never disappear!  I was thinking of things which we may not have managed as well as we could have done, suppressing what would otherwise be uncomfortable.  Or is the process far more prosaic, and we forget events that were truly unmemorable, uninteresting or irrelevant?  Perhaps my first visit to Finland, back in the 1970s, offers some insights.  Certainly, the headline moments involve fish, revolving restaurants, disappearing nights and smallpox.  One problem:  there is little else I remember about that visit.  What have I forgotten, and why?

Based in Scotland, I had become interested in the introduction of social science into the medical school curriculum, encouraging doctors in training to understand more of the psychology and sociology of patients and their impact on the course of diseases.  This began with work I undertook at the Edinburgh Medical School, but the issue was hot, and I was commissioned to undertake a review of progress in a number of medical schools, a European Community funded investigation that took me to several countries.

As I was putting together plans to visit universities in Sweden and Finland as part of the project, I decided to combine this with a short holiday with my wife and three children.  We were ready to go when we hit a snag.  There had been a smallpox outbreak in Yugoslavia (this happened in 1972), and, as a result, all travellers to the Continent were required to have a smallpox vaccination.  We rushed off to get our jabs, and then set off for our first stop, Stockholm.  Here is where memory disappears:  I have no idea how we travelled there, but I think we may have driven down to Newcastle and caught the ferry over to Gothenburg.

I do recall being in Stockholm.  We stayed in a hostel, which I had found through the Youth Hostels Association network.  It was central, amazingly so, as the hotel was actually a converted barge, and the Red Boat (Den Röda Båten) was moored on Södermalm, about half a mile from the Royal Palace, and a mile from the Vasa Museum.  However, Sweden can wait for another blog.  After I had met with a professor at the famous Karolinska Institute, a medical university, we left for Finland.  The second part of the trip might have seen us take a second ferry, from Stockholm to Turku, on Finland’s west coast, and from there went on to Helsinki.  My memory only clicks back into gear when we are in Helsinki.

The University of Helsinki is a major tertiary institution, having offered courses since 1640, and today has around 32,000 students and a distinguished pedigree.  The medical school is the leading centre in Finland, with around 3,000 students, and a world recognised faculty.  OK, you’ve got the general idea:  it was, and is, a prestigious and impressive place.  When I arrived there, I was expected, and presumed I would meet with one or two lecturer and possibly one of the administrative staff, who could brief me about the courses they offered and any other relevant information.  However, once inside I was whisked up to the Dean’s office.  I supposed this must be evidence of Finnish politeness.

The Dean asked me about my background and the review I was undertaking. Without remembering the exact words, the next part of the meeting went like this:

‘Where are you based?’

‘At the University of Edinburgh.’

‘Ah, good.  I have many friends among the Scottish people.’

At this point the Dean went over to a filing cabinet, opened a drawer and pulled out a bottle (which I was to discover contained schnapps) and two small glasses.  He filled each glass, handed mine over, remarking, “I hear the Scottish people can hold their drink like us.”  He tossed his drink back in one go, and I managed to do the same.  We did that three more times.

“Good, very good.  Just like us.”  The bottle and glasses disappeared, and I was ushered out.  To this day, I can’t believe I remained upright and sufficiently in command of myself to go on to interview the people who’d been arranged to meet me.  Well, I must have done so, because my report contained the data I collected in Helsinki.  Great introduction to Finland!

I was to go on to two more medical schools in Finland, but we’d decided that the family would stay just north of Helsinki in a lakeside cabin.  I would only be away for a couple of days.  We were in a resort area by a lake (how we got there, I cannot remember!), found our cabin, and the manager pointed out the sauna by the lake.  Enjoy a really hot sauna, and then jump in the freezing water … hmm.  The next morning, I heard something by the front door of the cabin.  Going out to check I found a carrier bag hanging on the handle with two fish inside – still alive!  I could hardly wait to get off to the airport.  I abandoned the family, with what I hoped was adequate food and drink, most of which we’d bought well in advance.

I went first to Tampere and was entertained there in one of those revolving restaurants on top of a tall tower.  I thought that was amazing, unique even, except I soon discovered almost every city I went to in Europe had a revolving restaurant on top of a tower.  The architect who came up with that idea must have made a killing.  I left later that day and flew up to Oulu.  Oulu is some 100 miles south of the Arctic Circle.  I arrived around 8 pm, and noticed it was still light, but I didn’t pay much attention.  I was living in Edinburgh, which had late sunsets in the summer.  However, at 11pm, as I was about to go to bed, I noticed it was still light, although all the streetlights were on.  The next day, I was talking to another guest at breakfast who explained that there would be only a couple of hours in the day when the sun was below the horizon, and even then, it didn’t get really get dark.  The streetlights were there for advice, to let you know when it was ‘night-time’!

When I arrived back at our lakeside cabin, my eight-year-old son wanted to talk to me, in private.  Before I had the chance to ask any questions, he took the towel around his shoulders away, and pointed at his arm.  From just above the shoulder joint right down to his elbow, it was covered in blisters.  He was unable to pull it down to his side.  He was in pain, and he was scared, too scared to even tell his mother.  We needed to see a doctor, quickly.

There was a bus stop just outside the tourist park.  We waited – and then realised we were standing on the wrong side of the road to get into the nearby township!  In the town, we looked for a doctor’s surgery.  Have you ever spent time in Finland?  If so, you will know Finnish is challenging.  It is one of the languages in what mis known as the Uralic Group, sharing some characteristics with Estonian, Hungarian, and the local speech of the Karelia region of Russia.   I guess the key point is that unless you are Finnish, or a Hungarian or Estonian speaker, it is totally opaque.  I decided we should look for some kind of medical sign (like a red cross) or a vehicle with emergency markings, like a police car.  Eventually we saw what had to be a local police car, with järjestyspoliisi written on the side.  I was so anxious I didn’t even notice the end of the name included a word like police.

By sign language and pointing, they showed us the location of a medical centre.  Now it had to be easier:  all I had to do was point to the inflamed arm, now held up a chin height, and there’d be action.  We were ushered into a doctor’s surgery, and I said something like ‘Son.  Reaction to smallpox jab’ and pointed.  The doctor smiled, and replied, in perfect English, “Dear me, that look’s most uncomfortable”.  Within a minute I discovered he was a graduate of the Edinburgh Medical School, knew my friend the Dean very well, and would have kept chatting for the next ten minutes were it not for an anxious ‘Dad’ from my son!  It turned out he had experienced a not uncommon side reaction to the vaccine, and with penicillin it would soon be fine, after a round of treatment.  Within a few days, as predicted, the lesions and swelling had all disappeared.

If I hadn’t realised it before, meeting that doctor brought home that the medical profession is a like a huge network, running across countries and continents, and, remarkably, in Europe and North American at least, with English as a common language.  Even if most aspects of living in Finland would be a challenge for English, French, German and other European language speakers, doctors were accessible.  A world within a world.

The visit to Finland was an early example of a lifestyle choice I have made many times since, combining work with some leisure, travelling to countries with my partner, and often with children.  I suppose the truth of the matter is that I had little time outside work, but the family had the opportunity to visit cities, museums, parks and shops, enjoying new cultures.  But having them with me did ensure that I spent some time away from work commitments.  In Sweden we’d all been to the Vasa Museum and it’s salvaged 17^th Century warship.  However,  one more recollection from the time Helsinki remains as vivid as it was that day.

For reasons I can’t remember, we went down to the main railway station.  The Helsinki Central Station is a massive art deco building.  Back in the 1970s there were none of the restrictions that exist today, and you could wander along the platforms.  That is what we did and watched the Helsinki-Leningrad express being prepared for its next journey.  This would take you to Russia, pulled by a steam engine (which looked massive), the small number of coaches complemented by what looked like a very posh restaurant car, and several wagons at the back, packed with?  Leningrad is St Petersburg now, and whatever black-market trading took place then would not be so obvious in the 21^st Century: certainly, the wagons would be more discreet.  As I looked, travel to Russia by train seemed the epitome of luxury:  if only!

Why do those few key moments remain so clear:  the visit to the lakeside resort; the schnapps with the Dean of the Helsinki Medical School; the dinner in the revolving restaurant in Tampere; the lights in the ’daylight’ late at night in Oulu; taking my son to the Edinburgh-educated doctor; and the visit to the Helsinki railway station?  Not especially memorable, but they all made a clear impression on me.  Why those particular interactions in the midst of travelling through Finland, among all the other things I saw and did?

One thing is quite clear.  We are more likely to remember an event as a function of its emotional impact.  In meeting the Dean at the University of Helsinki Medical School, I suspect what has made that brief drinking session stick in my mind I shamefacedly admit was almost certainly pride!  I managed to drink four small glasses of Schnapps on an empty stomach and survived, more than survived but continued on well enough to meet people, ask questions and take notes.  I can’t remember any of that, but I can still taste that schnapps.  As for meeting that doctor with my son, it wasn’t the facts of his past, but the emotional seesaw, from being really worried to a sense of relief in just a minute.  I can’t remember if I met up with the Edinburgh dean on my return and told him about my meeting with the doctor.

There have been some astonishing scenes in recent weeks.  We have seen bombs exploding in Ukrainian cities, Russian tanks in city streets, bodies left outside, and stream of refugees flooding over the border with Poland.  Of all the horrific and frightening sights, one image that sticks in my mind was of a Polish reception centre where refugees arrived from the war.  What I saw was dozens of people offering help, what I described as ‘a million small acts of kindness’.  The sight of ‘ordinary’ people on hand to offer food, clothing, transport, toys, anything to help desperate people, that had more emotional impact on me than most of the news items, together with the Ukrainian President Volodymyr Zelenskyy saying,“You are told that these flames will bring freedom to Ukraine. But the people of Ukraine are already free.” He added, “In attacking us, you will see our faces, not our backs.”  The compassion of people for one another, and the courage of a man we’d all like to be.  These are two images will remain in my memory for a long time, rather than televised scenes of explosions.

Here in Australia, we specialise in humour as the emotion to make points that matter.  There were a series of floods along the east coast recently, with several deaths and thousands of houses and shops destroyed.  Taking place as the prospect of a federal election was looming, the government was out to capitalise on its actions to help address the disaster, and, with consummate skill, managed to bungle much of their response, particularly in emphasising this was unanticipated.  Here’s the Aussie way to deal with that:

‘Politicians and media have labelled the devastating floods in Queensland and NSW a once-in-one-hundred year natural disaster, the eighteenth once-in-one-hundred year natural disaster in the past year!  NSW resident Helen McMannis said she would be telling the grandkids about the once-in-a-lifetime floods of 2022, after she’d finished telling them about the once-in-a-lifetime floods of 2021, the once-in-a-lifetime bushfires of 2020 and the once-in-a-lifetime pandemic of the past two years. “And then I’ll tell them about the once-in-a-generation dust storm, mice plague and smoke fog,” she said.  “I remember the last once-in-a-hundred year event like it was just last year. You won’t see something as bad as this again, until something worse comes along in a few months,” she said.’ [From The Nation, 2 March 2022.]

Well said, Helen McMannis.  We can contrast her words with those of Prime Minister Scott Morrison, claiming there was no way anyone could have predicted the latest floods. “It’s unprecedented. If only there had been some sort of body of scientific research that had pointed to more extreme weather, then we could actually do something about it”.  Surprised? You need to know that Scott Morrison is still reluctant to even admit there is such a thing as climate change, let alone recognise its consequences or address what Australia needs to do to minimise it.  His comments will soon disappear from my recollections of the early part of 2022, but those of Helen McMannis will remain much longer.

In some respects, Finland could not be more different from Australia.  It is a country of lakes, forests, a cool climate marked by a long cold winter.  Its land mass is 130,000 square miles, just 4% that of Australia; its population of 5.5m is one-fifth that of Australia.  Finland is a country of manufacturing, electronics and other goods, as well as forestry products, compared to Australia, which relies on the service sector, tourism and education, together with exporting natural resources and agricultural products.  Finland is a leader in innovation (5^th on the Global Innovation Index, Australia is at 25^th).  Similarities and differences, schnapps and whisky!  One very important comparison is that both are on the margins of geo-politics … little outposts of what the world could be like.  However, within these comparisons, there is one huge difference.  Finland has recognised that it must take determined action now to create a sustainable future.  If only Australia would realise it has to do the same.

Double Donuts

Moving between the US and Australia has revealed several areas of confusion.  Among the many, many things I do not understand, the current coronavirus pandemic is one.  I am not talking about the coronavirus itself.  The virus, depicted as a ball covered in spikes, is clear to me, and I continue to hope I can avoid it bouncing down into my system.  I know a little about how to be careful, and I have been vaccinated.  No, it’s not the virus and its multiplying variants that have me confused, but rather what is being done about controlling or eliminating it.

For many years, medical scientists and public health authorities have been concerned about the likelihood of a pandemic.  Largely invisible to most of us, they have been planning for and exploring future containment options.  Yes, largely invisible, but you can’t keep a good topic away from cinema screens, and in 1995 Wolfgang Petersen produced a classic with Outbreak.  Impressive at the time, it is even more prescient today.  Based on a non-fiction survey of viruses by Richard Preston (The Hot Zone), Outbreak depicts a deadly virus emerging from Africa, and eventually reaching the USA.  The core of the film covers various attempts to stop it spreading and is centred on dramatic events in the fictional town of Cedar Rapids.  There are all the familiar characters, the CDC, the military, researchers and medical staff, and heroic volunteers.  On more than one occasion I had thought of using it as a training film, great to focus the thinking of senior emergency services professionals.  Today, it would provide an even more telling perspective.

The SARS epidemic of 2003 gave a boost to films about worldwide disasters.  For those of you who like horror flicks, Steven Soderbergh’s Contagion, released in 2011, was a special treat.  In this rapidly spreading fictional pandemic we watch what are now familiar scenes off people trying to control an escalating emergency, with social distancing and hand washing, the race to produce a vaccine, panic buying, deserted airports and closed borders, and, above all, the spread of conspiracy theories and misinformation.  Apparently, in the past few months Contagion has become one of the most searched and downloaded titles on the web, even though it’s not available on Netflix nor on most of the other major streaming services.  Soderbergh takes the story further than we have seen with COVID-19 – so far – as the pandemic generates widespread social unrest, panic buying turns into riots, looting, home invasions and kidnappings. Uncollected garbage piles up on the streets while sporting venues are turned into makeshift hospitals with thousands of sufferers lined up in camp beds, and we see scenes of mass graves in which the dead are covered with quicklime.

As the date of Soderbergh’s film makes clear, it’s not the case the current coronavirus pandemic is something new and unprecedented.   As the COVID-19 outbreak grew, I remembered the SARS epidemic in South and East Asia.  The Severe Acute Respiratory Syndrome in 2002 was a shock.  At that stage I was travelling regularly to Singapore, Malaysia, Hong Kong and China.  As we now know, SARS developed in Asian palm civets, tree dwellers that in some ways resemble possums (but are completely unrelated), and the virus was passed on via horseshoe bats in China’s Yunnan Province.  Back then, we quickly discovered the disease was dangerous, with a mortality rate of 8-18%.  After a slow start, travel was restricted, and areas quarantined.  Eventually, there were around 8,000 cases, and some 1,000 deaths.  However, by 2004, SARS-CoV-1 had effectively disappeared. 

In the and epidemic aftermath, one outcome was fear, fed by the popular press with alarming articles describing how such a disease could emerge again.  Time after time frantic revelations suggested a new SARS strain was slowly being hatched in a remote jungle area, about to cross over from a variety of exotic animals, ready to sweep the world in an instant.  Around the same time as SARS, MERS appeared in the Middle East, another coronavirus disease:  MERS spread to around 1350 people between 2012 and 2020, with 527 deaths, an even higher mortality rate than SARS.  However, most attention to coronavirus epidemics was eclipsed by the Ebola outbreak in West Africa in December 2013.  Two years later this had resulted in nearly 29,000 cases and 11,323 deaths.  The Ebola virus hasn’t gone away and had been causing trouble since back in 1976.

Naturally, you would assume we were ready for the next pandemic.  Naturally, you would be wrong.  Back in 2014, the Barack Obama administration, collaborating with various countries and international organisations, launched the Global Health Security Agenda (GHSA), aimed at ensuring government pandemic preparedness.  The Trump administration didn’t drop the US commitment to the GHSA but did so while reducing funding for support staff and international capacity building:  overall, budgets for US pandemic preparedness fell to pre-2014 levels.  In 2018, the Group of Seven (G7) agreed epidemic threats deserved the same level of attention as other serious threats confronting countries, but while the G7 committed to supporting up to seventy-six countries in building core capabilities on no less than four occasions, there was no monitoring of action, and this effectively rendered these multilateral commitments largely meaningless.

In addition, most attention on pandemic preparedness was focussed on low- and middle-income countries for detection, preparedness, and response.  It seemed agencies had fallen into the trap of believing global health security is only as strong as its poorest link.  Possibly inevitably, since viruses don’t follow our bureaucratic rules, COVID-19 has had dramatic effects on prosperous countries as well as poorer ones, despite their relatively advanced health-care infrastructure.  The capacity to respond was shockingly low in most nations, and high-income countries have joined the rest of the world in being overwhelmed by the pandemic.  Countries that scored well on GHSA measures, including the US and UK, have struggled in their COVID-19 response: even they were underfunded and underprepared for no good reason.  Why?  It didn’t and still doesn’t make sense.

My next area of confusion concerns vaccines.  Prior to the past couple of years, my superficial knowledge of vaccines was largely influenced by the method used in the eradication of smallpox.  In simple terms, as best I understand it, vaccination against smallpox was initially achieved in the late 19th Century by infecting people with cowpox, a weak virus that leads to the production of antibodies to protect against the disease.  In more recent years, and after the virtual elimination of smallpox, production of Dryvax, a calf lymph smallpox vaccine, ceased in 1980.  Since then, some other animal-pox-based vaccines have been developed, just in case.  That was what I knew:  you were protected against a disease by being vaccinated with a weak or altered strain of the virus.

With the advent of COVID-19, the development of coronavirus vaccines has been truly astounding, with more than 20 approved for use, many achieving at least 95% preventive efficacy.  For that we can thank laboratories and government funded researchers who had been trying to make sense of SARS and MERS.  Some vaccines have been ground-breaking.  Pfizer and Moderna use what is called ‘messenger RNA’ (mRNA) injected into the body, which stimulates a response by teaching the body how to identify and destroy the corresponding virus.  An amazing new technology, all the more so as trials and subsequent tests have revealed severe allergic reactions are rare.  The other major development has been in ‘adenovirus vector’ vaccines, which do not make new virus particles, but rather produce only the antigen which elicits a continuing immune response.  These include the Oxford-AstraZeneca and Johnson and Johnson vaccines.  Despite wild rumours, like the mRNA vaccines these are remarkably free of severe side-effects, but all vaccines carry some risk.

Can you see why I am confused?  So far, what I can see is two things:  first, the existence of coronavirus viruses and their contagious nature was well known, with variants already being researched.  Second, some extraordinarily effective vaccines using new technologies have been developed very quickly.  The conclusion is obvious.  All should be good.  Except it isn’t.  Worldwide we are approaching 200m cases (and probably at least the same number again in undetected infections), with a death toll of around 4m, still growing.  How can this be?  That’s too big a question, so let me narrow it to the one that’s on my mind:  what is going on in Australia?

As I see it, there are three issues at stake here: politics, people and perspective.  Politics always plays its part any important event.  While outright lying is far from common, ‘shading’ the truth is normal fare.  Australia’s Prime Minister, Scott Morrison, is a marketing machine.  He is able to put a good spin on almost anything:  right now, he is reassuring us that his latest ‘recalibration’ of the path out of COVID-19 lockdowns will be achieved by a four-stage strategy.  In announcing this, in yet another story to convince a rather credulous population that the government is in control, he observed “Australia gets vaccinated, Australia is able to live differently.”  If only we had known this earlier!  The details of the first phase of the approach are that this ‘pre-vaccination’ phase is based on ‘suppression’ of the virus spread, until more of the population is vaccinated.  It involves widespread testing, extensive contact tracing, and – if required – community-wide restrictions, as are currently being imposed in several parts of the country.  But, to be clear, as one epidemiologist explained, “Until we get the vaccination coverage a lot higher, we have to re-eliminate this virus each time, and doing that unfortunately requires these lockdowns.” 

Hmm, but isn’t this first recalibrated phase the same as we have been experiencing for the past few months – cases emerging, contacts traced, partial or complete lockdowns, with moments when a state is clear of infections, before another case emerges and the cycle repeats?  Scott Morrison’s ability to promote a good story was at the fore as this initiative was explained.  Fortunately, no-one asked if we had the number of vaccines needed to vaccinate enough of the population, whatever that number might be.  80% of the population?  90%?  More than that, some say.  When will we reach this indefinable target?  By the end of the year, maybe, or sometime in 2022 … or 2023.  Another expert recently commented on what was being proposed: “Without supply and massive scale up of vaccination rates, as well as plans to vaccinate children, the roadmap is hypothetical.”

The politics of federal government reassurance are laughable enough, but in a federal system we have competition between the states, too.  In recent months, Victoria was the favourite punching bag.  They can’t control transmission, infections keep increasing, constant lockdowns, with NSW looking smugly on.  Oops, while Victoria seems has been managing, now it is NSW, that previous paragon of virtue, that is having to use the word ‘lockdown’, even if it took the state Premier some days to learn how to pronounce this unfamiliar (Victorian?) word.  As new cases pop up across various regions of Australia, snide comments abound, aggravated by jousting between the states run by Labor administrations and those run by the conservative coalition, (the same lot who are in power in Canberra).  It would be fun to juxtapose comments by any one of the state leaders from different dates in the past few months as situations changed, except this pandemic isn’t funny.

One of the battles, it is clear, lies with the broader population.  It doesn’t seem to matter how often we are asked to act on behalf of the community, nicely or assertively, there are always some people who put personal needs above everyone else.  In a country obsessed with sport, one such need is for devoted fans to get to watch a game at any cost, and some escape quarantine to do just that.  Others need their favourite food, want to see a close friend, go to a party; the list is never ending, but, without fail, every lockdown sees restrictions ignored by a minority who simply won’t do as they have been asked.  We live in a selfish world, as our approach to the ravages of COVID-19 in the developing world show:  our lack of adequate support is embarrassing.  The happy land down under has thrived on selfishness for the past 40 years.  Why should we have to change now?

Politics and people.  Both those issues are playing a role in the unfolding COVID-19 pandemic in Australia.  However, neither are confusing.  Politics has always seen a focus on telling good stories, and a necessary one-upmanship between the states.  People are people.  Some care about others, and some care only about themselves.  It is in relation to the third issue, seeing things in the right perspective, that I am in need of some clarification.

This is what I have read and understood.  COVID-19 is a contagious virus.  Some variants are more readily passed on than others.  The death rate, now we better understand both the illness and post-infection care, seems to be around 2-3%.  As with other diseases, the key strategy is to vaccinate at least 85-90% of the community to achieve ‘herd immunity’, at which point any new infection has a very low probability of spreading.  Since vaccines first appeared very early in 2021, many countries are already well on the way.   The UK and the USA have at least 50% of their populations fully vaccinated, closely followed by countries including Spain, Germany and Canada at 40% or more, and not far behind them are Italy and France.  In contrast, Australia’s progress is slow, now approaching 15% fully vaccinated, but full coverage is said to be unlikely before March 2022.

Is this because the government’s perspective is that we are an island, able to shut ourselves off from other countries, and keep infected visitors out?  For the past six months, it seems we consider it a success to have ‘double donut’ days, days without any new community infections or deaths.  Yes, I agree that is a significant achievement.  Against that, we remain vulnerable.  A slowly incubating but highly transmissible version of the virus could sweep through the country with ease, because so few Australians are protected.   Insulated from the rest of the world, we are assuming we have time, time to continue to keep the barriers in place and ensure the virus stays out while we gradually build up protection.  A comforting perspective, but previous pandemics have taught us two things.  Containment is critical, as is immunisation.  However, they also teach us that cases continue to appear.   It is impossible to stop new cases getting out.  COVID-19 is already back in Victoria.

As another round of infections is reported in Australia, a big moment on the evening news program is when a state declares its ‘double donut’ day.  Several double donuts suggest suppression is going well.  Here’s my source of confusion.  I admire the staff who are doing so well at containing the spread of the coronavirus.  However, I want to celebrate significant jumps in the percentage of people vaccinated.  Rather than hearing there are only a few new cases in Victoria, or none at all, I would like the lead story to be how many thousands have been vaccinated in the preceding 24 hours, and how many more this was than the day before.  Isn’t that the metric that’s the more important, measuring progress to the critical goal that should be uppermost – achieving herd immunity?  In saying this, I am betraying all the characteristics of a selfish Australian.  An equally important metric must be how many tens of millions of doses are being delivered to other countries, especially in the developing world.  If we are unable to give them free of charge or give the manufacturing process away, then we must help cover a part of the international bill.  The virus doesn’t need a passport, and if we care about the community, nor should we.  The whole world is in this together, and we should be making a major commitment to our neighbours.

My other confusion?  Albeit with a much higher mortality rate, I think about COVID-19 in the same way as I think about influenza.  The coronavirus isn’t going to be eliminated, certainly not for a few years.  It will continue to change, new variants will appear, and existing vaccinations will no longer be as effective.  We know that world.  Every year, we go to the doctor or clinic have this year’s ’flu ‘jab’.  There are hundreds of scientists working extremely hard at present to develop an approach to coronavirus protection for the future, not just for COVID-19.  Some of this is concerned with boosters, to add protection against specific new variants.  Others are trying to find a rather more powerful approach, a form of vaccination that detects and eliminates all forms of coronavirus. 

We have regularly thanked those nurses and doctors helping infected patients (the UK did an exceptional job in this regard).  I would like to hear regular news reports on the scientists and their work, and give them the recognition and praise they deserve, too.  Instead of having 5 minutes of my nightly news program showing the vaccine being injected (time filling at its worst), let’s have regular updates on the research and development side of pandemic prevention. Double donuts are nice, but ultimately indulgent (and dangerous to waistlines and health).  Increasing number of vaccinations, enhancements in vaccine strategies, aren’t these also news items that matter?

Codling Moths, Catalina and Other Calamities

We had three fruit trees in the back garden of my childhood home. One was a plum tree, and the other two were apple trees, including a Cox’s Orange Pippin.  It was hard to accept waiting for the fruit to ripen, especially when I looked over at the apple trees.  As the apples grew, they looked increasingly tempting.  Usually greed overtook patience, and I’d pull one off.  My mother had told me I would know if the fruit was ripe, because it would come away easily.  Huh.  Yank, and munch, and … another bitter tasting fruit!  Mum would scold me, and I would try to wait a little longer, knowing I was being watched from the kitchen window.  But boys of my age knew what to do:  we went scrumping. [i]  Scrumping sounds better than stealing, but it was stealing fruit from a nearby garden, hopping over a fence or reaching down from an overhanging branch.

Whether scrumped or legally obtained, munching an apple in those days did have some risks.  If you didn’t look carefully, an enthusiastic bite might include taking in at least part of a maggot hiding inside the fruit.  Alas, I must have eaten a few over the years!  Of course, if I looked carefully, I would have seen the evidence of a maggot attack, as the entry hole would be covered with some sticky bits of dried waste.  Those maggots were actually caterpillars, the larval stage of the Codling Moth, (Cydia pomonella).  In the US, the equivalent pest is the larva of a variety of the fruit fly, the apple maggot (Rhagoletis pomonella), also known as the railroad worm. [ii]  The maggots didn’t have a noticeable taste, but all us schoolkids agreed, they were horrible!

From the 1970’s onwards, apple production became big business, and out of the 2,000 or so varieties that are known, the focus was on round, colourful, soft yet still slightly crisp apples, if somewhat tasteless compared to past examples.  In a supermarket you will see Red and Golden Delicious, Fuji and Gala, Braeburn, Honeycrisp, McIntosh and Pink Lady, and that old standby, Granny Smith for cooking.  Cox’s Orange Pippins almost disappeared, as they were frequently mis-shapen and unsuited to the demands of supermarket uniformity.  However, in the last decade or so, some of those once popular but almost vanished varieties have been making a comeback, especially with a push from organic growers.  Whatever the variety, in the largely anodyne world of the apple today, I doubt many (if any) people now chomp on a maggot.

There is an apple in front of me right now, as I am typing.  This is the stylised apple of Apple, the image of a Golden Delicious, I would guess, with a nice chunk removed on one side.  I haven’t always been an Apple user: my life with word processing began with Wang terminals and WordPerfect, and from there I moved quickly on to the IBM personal computer (the XT was the first I used, back in 1984), and soon I was living with the DOS operating system and the slow invasion of Microsoft with MS-DOS, then Word.  For the next 25 years I was a devoted IBM-clone user, and Microsoft Office held my work tools, especially Word and PowerPoint.

Arriving in the US ten years ago, we went off to a big box store, Best Buy, to buy a computer for home.  I’m not certain what we intended as we walked in, but two hours later we walked out total ‘Appled’ with a Mac, a MacBook, and an iPad.  We held on to our mobiles, two Samsung flip phones, but one was soon replaced by an iPhone.  I had retained my Australian iPhone to use when travelling overseas, but I continued to use my Samsung in the USA for several years.  Now we have two Macs, a MacBook, three iPads, and three iPhones.

The transition to Apple was easier than I had anticipated.  After some minor mishaps, everything worked perfectly and seamlessly between devices. The screen on the Mac was a delight, making  my photographs look positively professional. The current background is a Red-Shouldered Hawk standing on a branch in our garden, the boughs glistening with raindrops.  I stuck with Firefox as my browser for years, but slowly, almost unnoticeably, I drifted over to Safari.  I’ve resisted the Apple alternatives for word processing, presentations and spreadsheets:  perhaps it’s habit, but I still like ubiquitous Word, PowerPoint and Excel.  I loaded some of my favourite music into iTunes.  I tried out iBooks (now just Books) and slowly built up a small library on my iPad for travel.  I don’t know how, but now there are 274 books in that library!  Yup, totally Appled.

Was I entranced by style and design?  A little bit.  Ease of use, and ability to transfer between devices?  Quite a lot.  Whatever the initial reason, once I was in, I was in:  today, I find it hard to remember IBM clones, and even harder to imagine how I would work using them once more.  It’s silly, I know, and, if I transitioned back, in no time at all it would be just as easy as it used to be.  The little things would be annoying:  where is the button to close something?  It’s not where it should be.  To be honest, I spend the majority of my computer time using Word, and apart from minor screen layout issues, it would be the same on most systems.

There’s more to this story, of course, and that has to do with changes over time.  I was disappointed when Apple decided to get rid of the iBooks bookcase, so now book covers ‘float’ unattached in rows on the screen.  I was disappointed to lose the CD/DVD read and write option when I got a newer Mac.  I wish the built in camera in the Mac had the ability to zoom in and out.  On the other hand, I am delighted I no longer have to replace batteries in the mouse and keyboard.  Next up, I am thinking of getting some wireless (Bluetooth) headphones.

Some other changes are rather more than minor disappointments.  I have to pay a yearly fee to use Microsoft Office, and each version is getting bigger and bigger in terms of disk space, and bigger and bigger in terms of options.  I would love Microsoft to offer a simple Word package, Microsoft Light.  There are so many functions I never use, and never will.  The other is deciding what to do about using cloud-based storage.  I managed to avoid it for a long time, but I store my photographs on the Mac, and now the collection has grown to the point where some have been offloaded to the cloud.  As Trump the Chump remarked the other day, it is what it is.

Now to the frustrations.  The equivalent of eating half a maggot in the world of apples as a fruit are upgrades in the world of Apple as a system.  I know upgrades address malfunctions and potential virus threats.  Good.  But there are also wider system upgrades, and to date I’ve gone along with them.  As I am typing, I am using macOS Catalina.  Within that version, I get a correction or enhancement every two weeks or so.  On average, each requires the system to shut down, new software downloaded, and then I wait while the new system replaces the old one.  It can take 2 hours, and, almost without fail, another 1-3 hours to sort out any minor problems the process creates.  I feel I’m teetering on the edge of disaster, while my normally equable self becomes more like a grumpy curmudgeon.  Not good for my temper, and not good for my health.

It’s not just Apple.  I get regular updates from Microsoft.  I get regular updates on the various ‘apps’ I use (not that I have many).  I would guess that every other day there is something being upgraded, improved, additionally protected.  When I am getting especially niggled, I can foresee a future in which I’m allowed a maximum of 2-3 hours work time, while the rest of the day is devoted to ‘fixes’.  Apples and Apple, both ever changing elements of the world we live in.

Sixty years ago, I could take an apple off the tree (if my mother wasn’t watching), possibly check for any obvious infestation, and then enjoy the fresh, rich and snappy taste of a misshapen but delicious Cox’s Orange Pippin.  Small risk, high flavour.  I don’t eat many apples now.  The closest with any real taste seems to be Fuji (I think).  Apples today are big and flavourless, but I haven’t bitten in to a maggot in years!  That seems to be the way of most fruits, bags of largely tasteless coloured water.  Bananas are good, and so are in-season cherries, raspberries, and varieties of plum.  In my local supermarket there is an area for organic fruits and vegetables. I thought they were all organic?  Oh, never mind.  In most cases, the organic version is clearly better than the ‘inorganic’ version, some especially tasty, like organic heirloom tomatoes.

How did we get here?  Careful varietal manipulation, and even some genetic modifications, have resulted in almost perfect fruit (in terms of consistent shape, size and colour).  At the same time, calamity lurks.  An outbreak of some pest or other can decimate crops, and a fruit or vegetable can disappear off the shelves for days, even weeks.  Hardworking bugs eye over acres of tempting red apples and await the next random chromosomal alteration that will make them impervious to protective treatments, and then we’ll find ourselves eating maggots for tea!

It’s time to talk about bananas, because the banana illustrates the risks in this. [iii]  The banana story begins many years ago.  There are many kinds of banana in the world, but until the second half of the 20th century, the dominant variety was the Gros Michel, tastier and more difficult to bruise than any of the others.  Then, in the middle of the 1950s, the crop was attacked by a strain of Panama disease, also known as banana wilt, an easily spread, noxious, soil-dwelling fungus.  Desperate for a solution, the world’s banana farmers turned to another variety, the Cavendish. The Cavendish was resistant to the disease and it met other market needs: it could stay green for several weeks after being harvested (ideal for shipping to Europe), it was prolific, and it looked good in stores. Equally important, there was no choice!  Multinational fruit companies had no other disease-resistant variety available that could be introduced quickly for mass production.

The switched worked. As the Gros Michel was ravaged by disease, the Cavendish banana took over.  Today, almost the entire banana supply chain is set up around that variety.  However, like any fruit, it remains at risk.  Years ago scientists warned the world’s largest banana exporters Panama Disease could return, with a variant that could hit the Cavendish hard, possibly within 10 to 30 years.  Late last year Colombia confirmed Tropical Race 4 (TR4), a strain of Panama disease, had appeared on Cavendish banana farms and the country declared a national state of emergency.  Now the same disease is appearing in Ecuador, Costa Rica and Guatemala.

There’s a name for this situation: monoculture, the practice of concentrating on just one variety of a product.  Monoculture has its benefits.  Standardisation largely eliminates the need for new production and harvesting processes, as everything is established and familiar to users. On the other hand, as the banana story makes clear, in a monoculture every producer is prone to the same attack. If someone or something figures out how to affect one crop, the entire system is put at risk.  In the case of bananas, if they’re under threat from a single disease, the fungus may be easily spread, from truck tyres or workers’ boots: it’s hard to contain. As most banana farmers are growing the Cavendish variety, their crops are all vulnerable to this new infection.

“The story of the banana is really the story of modern agriculture exemplified in a single fruit,” says Daniel Bebber, who leads the BananaEx research group at the UK’s  University of Exeter. “It has all of the ingredients of equitability and sustainability issues, disease pressure, and climate change impact all in one. It’s a very good lesson for us.”  He believes the lesson is simple: “A lot of people would agree that we need to move to a more diverse, more sustainable system for bananas and agriculture in general,” says Bebber, “where we don’t put all our hope into a single, genetically identical crop.” [iv]  Monocultures are major calamities in waiting.

The banana story is a lesson for more than plants.  There are other ‘monocultures’, like Microsoft Windows and Apple OS systems in the computer world.  All those computers using Windows, for example, offer a huge, enticing crop:  all it takes is for a virus to worm its way in, and it can maim and destroy to its heart’s content!  Disastrous!  Indeed, many software attacks resemble Panama disease’s threat to bananas;  uniform software systems offer uniform vulnerabilities. Back in 1988, the Morris Worm infected an estimated 10% of all computers on the Internet in just 24 hours; more recently, the 2016 Mirai Botnet, which allowed an outside party to remotely control a network of devices, brought down Twitter, Netflix, CNN and more.

“Monocultures are dangerous in almost every facet of life,” according Fred B. Schneider, a cybersecurity expert at Cornell University. “With people, of course, populations are stronger and more disease-resistant if there’s more genetic diversity. And with transportation, it’s more effective to have several different options—when a train line is shut down, if you have other choices at your disposal, like a car or another form of transit, you won’t be stuck.” [v]  Schneider points out that software monocultures are common because, without them, using your computer would be a lot harder.  Standard configuration settings, for example, make it easy to help users who may not be experts in the technology to set up and implement their software.  I’m a good example:  wherever I go I assume Windows is available for presentations or notes.  Uniformity for ease of use means we end up with common systems vulnerable to nasty viruses.  Software engineers today are learning from agriculture.  If banana growers are seeking crop diversity, so program developers are introducing diversity into systems. Microsoft has done this in Windows by randomizing the internal locations where important pieces of system data are stored.

The pressure to introduce uniform, easily managed monocultures are immense, as they reduce costs, simplify processes, and increase profits.  By avoiding expensive complexity and diversity, danger lurks just around the corner.  The coronavirus targets humans’ common biochemical pathways, malicious worms attack computers and networks, and pests destroy food varieties.  Smart computer systems, like many banana varieties, can help.  So can robust human immune systems.  Recent research shows over-protected children tend to have weaker germ resistance, and that means … gosh, that maybe eating dirt and a few maggots can be beneficial!

[i] Scrumping comes from ‘scrump’, an old word for a withered apple, not scrumptious, as I would have guessed!

[ii] Notice how both these species names include ‘Pom’?  Those French get everywhere!

[iii] Much of this draws on Anna Kambhampaty’s article at https://time.com/5730790/banana-panama-disease/

[iv] Cited by Kambhampaty, op cit

[v] Ibid

U is for Utilitarianism

One of the more extraordinary proposals to be aired as the coronavirus pandemic developed was that we should develop ‘herd immunity’.  You might be mistaken into believing this is something to do with protecting cows or sheep, but no, the approach was for the human herd.

Herd immunity is a concept used by epidemiologists to describe the situation where a population is sufficiently resistant to a disease that infection is unlikely to spread.  This is the result of so many people having acquired immunity, either through vaccination or natural antibodies, that any others are protected.  The key word in this is ‘vaccination’.  For example, mumps is a very infectious and unpleasant disease and can cause complications for an unlucky few, but it’s vaccine-preventable, and the disease is incredibly rare in the modern age.  Without getting too technical, the rate of infection from mumps is such that you need 92 percent of the population to be immune for the disease to end the risk, a ‘herd immunity’ threshold that has been reached by universal mumps vaccinations.  For coronavirus, we would need at least a 70% immunity rate to establish herd immunity, or, as we don’t have a vaccine, 250m in the US having been infected.  Achieving this would probably see some 3m people dying (some put the figure much higher).

Obviously, you would only plan for herd immunity when a vaccine has been developed, and not one second earlier, because it would be essential to safely stop an epidemic growing. [i]  Herd immunity without a vaccine is surely inconceivable.  If you want to be convinced, even Donald Trump says so:  “It would have been very catastrophic I think if that would have happened.”  He was commenting on the UK government’s original coronavirus strategy plan, which involved allowing the virus to spread in order to achieve antibody resistance to the virus in the population, an approach which would have caused millions of deaths if it had been adopted by the UK. [ii]

Population immunity against infectious diseases is one example of utilitarianism in practice. [iii]  Utilitarianism is a moral and/or practical approach, where the right action to pursue is the one which produces the most good, happiness or ‘utility’.  Doing what is good is to be understood entirely in terms of  the consequences it produces.  This leads to the view you should seek to maximize overall happiness by increasing benefits for others, not just yourself, to bring about ‘the greatest amount of good for the greatest number’.  Utilitarianism is both impartial and neutral:  everyone’s happiness counts the same. In other words, when we maximise ‘the good’, it is the good impartially judged; my happiness counts for no more than anyone else’s. Further, the reason I have to promote the overall good is the same reason anybody else has to:  it is not specific to me.  As we know, this is a far from uncontroversial approach, rubbing up against the claims of anti-vaxxers on the one hand, and super-rich doom-preppers on the other.

The concept of utilitarianism was developed back in the late 18^th/early 19^th Century.  Its main architects, Jeremy Bentham and John Stuart Mill, were concerned with legal and social reform.  Although they differed in some important ways, both wanted to see useless or corrupt laws and social practices changed.  In particular, Bentham considered some laws were bad because of their lack of utility, their tendency to lead to unhappiness and misery without any compensating happiness.   What distinguishes his ‘classical’ approach to utilitarianism is that Bentham viewed the moral quality of an action to be determined instrumentally. He believed actions shouldn’t be based on the view they were intrinsically wrong; rather actions were seen to be wrong by their effects, they were practically wrong. This contradicts the common view that some actions are wrong by their nature, regardless of their consequences.  Before his time, some behaviour was seen as intrinsically wrong or ‘unnatural’, some sexual practices for example, but Bentham dismissed this as a legitimate criterion. Others might be seen as wrong because they violated liberty, or autonomy.  Bentham viewed the value of these, too, only on instrumental grounds, not on an intrinsic moral basis.  Bentham was at an extreme.  His approach was far removed from other approaches, like Kant’s for example, which rested on fundamental principles, or from appeals to natural law.  For Bentham, it was happiness, measured by the calculation of outcomes.

The other great advocate of what we now call ‘classical utilitarianism’ was John Stuart Mill.  Mill was a follower of Bentham, and for most of the time he clearly admired Bentham’s work. However, he disagreed with some of Bentham’s claims, particularly on the nature of ‘utility’. Because Bentham had claimed  there were no qualitative differences between pleasures, only quantitative ones, his views led to some odd outcomes.  In his eyes, enjoying a glass beer in front of the television is comparable to solving a scientific problem, reading Shakespeare, or listening to Beethoven’s late string quartets.  Well, possibly, but it suggests human pleasures are of no more value than animal pleasures and, by implication, the moral status of animals, as conscious beings, is the same as for humans. Harming a dog and harming a person are both bad, but most view harming a person as worse, (although today some, like Peter Singer, might disagree).

Mill considered these consequences as unacceptable.  As he saw it, intellectual pleasures are of a higher, better sort than the ones that are merely sensual, the ones we share with animals.  Given this, Mill wanted to square his views with being a utilitarian.  He argued people who have experienced both intellectual and sensual pleasures view the former as better than the latter. To use his most famous example, it is better to be Socrates ‘dissatisfied’ than a fool ‘satisfied’.  In identifying ‘higher goods’, Mill had fundamentally modified the logic of utilitarianism.

Indeed, if Bentham was a purist in his approach, Mill also accepted much more than ‘happiness’ into assessing utility.  He placed weight on the effectiveness of internal sanctions, emotions like guilt and remorse which serve to regulate our actions.  This is an off-shoot of Mill’s particular view of human nature.  Human beings have social feelings, feelings for others, not just for themselves. We care about other people, and when we see them being harmed, this causes pain for us, too.  Further, when we are the source of that harmful action, the negative emotions aroused are centered on ourselves, feeling guilt for what we have done, distinct from the moral censure we apply to others’ actions.  Like external forms of punishment, these internal sanctions are important in shaping how we act.  Mill also believed a sense of justice, human psychology and conscience all underwrite motivation.  He argued a sense of justice, for example, results from very natural impulses.  Part of this involves a desire to punish those who have harmed others, and this desire in turn “…is a spontaneous outgrowth from two sentiments, both in the highest degree natural … the impulse of self-defense, and the feeling of sympathy.” [iv]

Like Bentham, Mill considered utilitarianism to provide the basis for law and social policy.  The aim of increasing happiness justified his arguments for women’s suffrage and free speech.  In his view, we can be said to have certain rights, but these rights are underwritten by utility.  The corollary was true too: if  a purported right or duty is harmful, then it is not genuine.  One of Mills most famous arguments to this effect can be found in his writing on women’s suffrage when he discusses marriage, noting that the ideal exists between individuals of “cultivated faculties” who influence each other equally.  Improving the social status of women was important because they were capable of these cultivated faculties, and denying them access to education and other opportunities for development would be forgoing a significant source of happiness.  He viewed men who would deny women the opportunity for education, self-improvement, and political expression as doing so out of ‘base motives’. [v]  Quite right, too.

However, by adding to Bentham’s instrumental utilitarianism, Mill also destroyed its clarity.  The right thing to do was no longer measured in assessing the practical consequences of actions, but was extended to their moral assessment, thus enlarging the precept to embrace ‘virtue’.  Mill argued that virtue is not only to be assessed by instrumental outcomes, but to live a virtuous life is also part of the good life. A person without virtue is morally lacking, unable to promote the good.  This formulation was important for Mill.  If Bentham’s model was accepted, it implied we had a ‘duty’ to pursue the greater good, and that would justify social and government action to ensure this, precisely what Mill was opposed to in his writing on liberty.  However, virtuous actions are those which it is “for the general interest that they remain free.” [vi]  His emphasis on freedom for the individual to choose the good thing to do undermined Bentham’s practical utilitarianism, leaving choice to personal preference, however well justified on moral grounds.  Bentham’s approach was much clearer, but for most of us, Mill’s is rather more acceptable!

Utilitarianism is one of the major solutions to the age old problem of justice: what is the right thing to do?  In pursuing virtue, Mill was shifting attention away from outcomes to underlying moral principles.  In the same way, Kant had argued for categorical imperatives, principles that are intrinsically valid, that are good in and of themselves, and are to be obeyed in all situations and circumstances if we are to observe the moral law.  These principles can only be based on something that is an “end in itself”, and have to be universal.  What is right to do is to follow these principles, without exception.  As later writers have pointed out, that’s not as easy as it sounds.  The familiar example is the principle ‘never lie’, and the challenge of keeping to this rule for those hiding Jewish people from the Gestapo during the Second World War.

In more recent times, Rawls argued for justice as equality, an approach which leads to policies such as affirmative action; libertarians go in the opposite direction, seeking to remove any form of coercion.  There also some, like Judith Shklar, who have suggested we should go down yet a third path, choosing our actions on the basis of not causing harm.

If we step away from philosophical debates, it is clear actions for ‘the greater good’ are central to individual behaviour and social practices today.  At one extreme, we can look at the conduct of war.  Volunteering in the two World Wars, later superseded by conscription, saw millions of young people sacrificed for the sake of the country.  Mill would have argued they died to ensure liberty, democracy, and freedom from fear; Bentham that they were dying to save the lives of others. Similarly, even if they might have disagreed on the exact reasons, they would have agreed we expect firefighters and the police to take risks for our benefit .  The idea of the greater good is implicitly understood in our appreciation of what people like these do.

In the case of soldiers, firefighters or police, it tends to be younger adults who are acting for the common good.  But it can the other way around.  Older people want the young to survive.  For example, in her novels Martha Grimes’ Superintendent Richard Jury from Scotland Yard is a rather lonely figure, close to depressed much of the time.  However, he is galvanised when a young person is under threat or murdered.  They have their lives ahead of them.  You know that, if it came to the pinch, he would sacrifice himself for a youngster, a straightforward ‘greater good’ perspective, an example of how older people offer to sacrifice themselves for the young.

This takes us right back to Covid-19.  Back in late March, Texas Lieutenant Governor Dan Patrick (a Republican) argued  that the elderly ought to be willing to die from COVID-19 for the sake of the economy. During an interview with Fox News host Tucker Carlson, Patrick argued that social distancing measures against the coronavirus should be lifted to let Americans go back to work, even if this led to increased numbers of older people becoming infected with the illness.  “Those of us who are 70+, we’ll take care of ourselves but don’t sacrifice the country,” Patrick said. “Don’t do that.  Don’t ruin this great American Dream.”  The lieutenant governor asserted that grandparents have a “choice” to make in the face of “total collapse” in the economy.  “We all want to live.  We all want to live with our grandchildren as long as we can,” he said. “But the point is our biggest gift we give to our country and our children and our grandchildren is the legacy of our country, and right now, that is at risk.” [vii]  Patrick’s comments came as other Republicans, including President Donald Trump, were pushing for an end of social distancing in order to rescue the ‘sinking economy’, even as the coronavirus continued to roil the country.

He was ridiculed, but surely this was a utilitarian approach.  I wasn’t surprised by the criticism he received, but suppose he had argued, in the face of increasing pressure on ICU places and ventilators, older people should refuse ventilator support for the sake of younger patients?  This was a real issue, and will be in the future.  In fact, rationing of care is an ever-present dilemma.  We appear to prefer seeing it swept under the carpet, knowing, guiltily, that doctors are being forced to make decisions like these.  Should determining the greater good be left to pressured medical practitioners alone?  Would it not be better to allow older sick people to make that decision themselves?  If Bentham was with us, he would have no doubt: when hospitals are overwhelmed, push the oldest out of the ICU beds first: utilitarianism before rights.  Mill would want people to have the freedom to choose: sadly, that ‘liberty’ could well mean the rich would continue to demand every kind of life prolonging care at the expense of younger, less ill patients.  Neither would be happy to see the principles at stake hidden behind closed bedside curtains.

We live in a world dominated by utilitarian practice, albeit in a rather modern, twisted variant.  Actions are taken for the greater good, but not necessarily the greater good of the majority.  It is often affluent minorities happiness pursued at the expense of poor majorities; affluent nations enjoying life at the expense of huge poor third world countries.  Hang on: I think I may have got my words mixed up.  I am describing exploitation, not utilitarianism.

[i] For more see: https://www.sciencealert.com/why-herd-immunity-will-not-save-us-from-the-covid-19-pandemic

[ii] https://www.businessinsider.com/donald-trump-uk-herd-immunity-coronavirus-catastrophic-boris-johnson-covid-2020-4-1

[iii] A good summary of utilitarianism can be found in https://plato.stanford.edu/entries/utilitarianism-history/

[iv] Ibid

[v] Ibid.  Also J S Mill, The Subjection of Women, Longman, Green Reader and Dyer, 1869; republished many times

[vi] Utilitarianism, Parker, Son and Bourn, 1863; see also Part d, iii in https://www.iep.utm.edu/milljs/#SSH2d.ii

[vii] https://talkingpointsmemo.com/news/texas-dan-patrick-grandparents-sacrifice-lives-coronavirus-economy

To Share or Not to Share

In my postgraduate course on Commercialising Innovation I review intellectual property (IP) and the laws surrounding its protection and use.  When we reach this stage in the program, I feel we are confronting a topic at a watershed:  on one side is the traditional IP system, and the rules surrounding patents, copyrights, etc.; on the other side there is an unclear and emerging regime, forced on us by having to deal with a digital world where most information is generally available cost free. The transition is recent, roughly before and after 2000, and we’re still in the watershed, the terrain is misty, marshy and muddling.  This is a huge topic, with many books and journals, and a plethora of complications and competing issues.  The millions of words make it clear the system’s riddled with stresses and strains.  Two examples to illustrate the challenges, before moving on to briefly consider whether we could change much of what is being done right now.  Can we rethink IP protection in the 21^st Century?  Or even abandon protection altogether?

The world of IP protection had been relatively straightforward to the end of the 20^th Century as it dealt with intellectual activity manifested in things, objects. Most patents were applied to inventions, physical devices that contained a novel technology, quite often devices you could see, touch and easily take apart.  Similarly, copyright was ‘visible’, covering intellectual activity realised in creative works, written materials and visual items ranging from artworks to designs.

Both these forms of protection have a long history, reaching back to medieval English law.  The 1624 Statute of Monopolies is considered the origin of patent law; the Statute of Queen Anne in 1710 the first step in copyright.  Inevitably, early simplicity has been overtaken by complex rules and regulations, and steadily accumulating legal precedents.  Global consistency in IP protection provisions is the responsibility of the World Intellectual Property Organisation, (WIPO), which defines IP as “creations of the mind, such as inventions; literary and artistic works; designs; and symbols, names and images used in commerce  …  By striking the right balance between the interests of innovators and the wider public interest, the IP system aims to foster an environment in which creativity and innovation can flourish”. [i]  To achieve this, IP laws give people and businesses rights for a limited period of time, giving “economic incentive for their creation, because it allows people to profit from the information and intellectual goods they create. These economic incentives are expected to stimulate innovation and contribute to the technological progress of countries, which depends on the extent of protection granted to innovators”. [ii] 

In this system, commentators agree the word property “presents difficulties when compared with traditional property like land or goods. Unlike traditional property, intellectual property is “indivisible”, since an unlimited number of people can “consume” an intellectual good without it being depleted. Additionally, investments in intellectual goods suffer from problems of appropriation: a landowner can surround their land with a robust fence and hire armed guards to protect it, but a producer of information or literature can usually do very little to stop their first buyer from replicating it and selling it at a lower price. Balancing rights so that they are strong enough to encourage the creation of intellectual goods but not so strong that they prevent the goods’ wide use is the primary focus of modern intellectual property law.” [iii]

Sounds good, but in the last 20 years, strains have been growing, well illustrated in two cases, the first concerning patents and genetic materials, the second over copyright extensions.

Traditionally, a patent was granted for an invention (based on a novel idea), most often a new method or process of manufacture.  By definition a patent can only be granted if the proposal is demonstrably new, and involves an ‘inventive step’.  As you can imagine, patenting takes some time as the registration system requires extensive checking to ensure this innovation has not been created before.  Ownership is granted to the inventor or person (and companies are ‘persons’ in law) who derives ownership through the inventor.  This usually means employees cannot claim a patent if they developed an innovation in the course of their work. [iv]   Patentable subject matter includes processes, substances, business methods, computer programs, and games, but not algorithms, discoveries, methods of human treatment, living organisms, computer program as such, nor “laws of nature, naturally occurring physical phenomena, and abstract ideas”.

Enter big business, as companies have increasingly sought patents for processes that were not inventions, but discoveries, (together with claims for new methods of human treatment).  A major issue has centred around the patenting of human genes.  This took off after June 2000 when the human genome was almost completely mapped.  Private and public entities unleashed a flood of patent requests for genes and parts of gene sequences. There are some 30,000 human genes, and up to 15% of these were patented.  To be clear, a gene patent gives an exclusive right to a specific sequence of DNA, whereby the patent holder, usually a company, has sole control over how the gene can be used in commercial settings, such as clinical genetic testing, and in non-commercial settings, including research, for 20 years from the date of issuing the patent.

This situation changed on June 13, 2013, when the U.S. Supreme Court unanimously ruled that naturally occurring genes and genetic sequences were not patentable. The case centered on patents for the genes BRCA1 and BRCA2, genes found in all humans, but mutations in which increase the risk for breast cancer.  It invalidated the patents on these genes, because DNA is a “product of nature.”  Correctly, the Court decided that because nothing new was created in discovering a gene, there was no intellectual property to protect.  Prior to this ruling, more than 4,300 human genes had been patented, but the Supreme Court’s decision invalidated those gene patents, making the genes readily accessible for research and for commercial use in testing.

Excellent, you might think.  However, the decision of the Supreme Court contained a further decision, one which supports patenting, even though their decision appeared to deny gene patents.  In its ruling the Court did allow DNA manipulated in a lab to be eligible for patenting on the grounds DNA sequences altered by humans are not found in nature.  In essence, the Court allowed the patentability of a type of DNA known as complementary DNA (cDNA). This form of DNA is produced from the molecule that gives the instructions for making proteins (called messenger RNA).  In other words, while the decision by the Court on the non-patentability of natural genes was clear and irrefutable, with regard to the patentability of cDNA, the Court held that “cDNA does not present the same obstacles to patentability as naturally occurring, isolated DNA segments”.  As you can imagine, this distinction has raised considerable controversy, many arguing “cDNA is not patent eligible [because] the nucleotide sequence of cDNA is dictated by nature, not by the lab technician”.  Without getting bogged down, cDNa is what our DNA would look like if it were purged of all introns (DNA segments which are not part of genetic instructions, and eliminated when the DNA is copied to form RNA).  The Court argued, wrongly, “cDNA is an artificial creation, even though it contains the same data as the mRNA, which is a natural creation.” [v]  It’s a fine distinction, but enough for the Supreme Court, stating “the lab technician unquestionably creates something new when cDNA is made”.

What’s going on here?  Let me try an analogy.  Let us suppose a man asks his neighbour to keep an eye on his house while he is overseas for a month.  In the garage are three cars, including a beautifully maintained 1972 MGB.  Aware of this, the neighbour had converted his garage into workshop, with a cleverly adapted pneumatic jack.  He drove the car around to his garage  Over the next two weeks he took it completely apart, and then reassembled it.  He had the MGB ready to drive, even emptying the ashtray and cleaning the carpets.  When the owner returned from overseas, he went to his neighbour to find his car.  ‘It’s mine now: I completely reassembled it!”  Would that stand up in court?  No, it was still the neighbour’s car (even though the neighbour had cleaned it, of course!).  So why would reassembled DNA be any different?  The Supreme Court’s decision wasn’t only about one piece of DNA (one reassembled car, as it were).  Rather it can be used by courts to justify patent claims in cases where a man made contribution was made, however trivial, to pre-existing natural matter, with the result no distinction remains between discoveries and technology, allowing the appropriation of natural matter by companies.[vi]  Biotech companies have been delighted at the control they can acquire.  Big business wins yet again.

The second case has to do with copyright, and in particular with Disney’s antics to keep Mickey Mouse protected (in so doing, making the copyright law ‘mickey mouse’!).  This may also seem rather technical, but it is worth reading on as the outcome is important here, too.

When copyright law was first codified in the United States under the United States Copyright Act of 1790, the copyright duration was limited to 14 years but included a provision that it could be extended for an additional 14-year term if the creator was alive. Years later, in 1831, the Act was amended to allow for an initial 28-year term, with eligibility for a 14-year extension, and, in 1909, the Act was changed yet again to allow for a 28-year renewal instead.  In 1928, Walt Disney released the first Mickey Mouse cartoon: Steamboat Willie. At that point, Mickey was entitled to protection for 56 years (28 years for the initial term and the 28-year extension).  On that basis, copyright on Mickey Mouse was to expire in 1984.

However, rather than lose control over the mouse, in 1984 (interesting date?) Disney lobbied Congress to change the Act.  They succeeded: in 1976 Congress passed legislation to change the copyright scheme.  Now individual authors were granted copyright protection in their lifetime, plus an additional 50 years!  For works authored by a corporation, the legislation granted a retroactive extension for works published before the new system took effect. Now the maximum term for already-published works went from 56 to 75 years, extending Mickey’s protection out to 2003.  But Disney wasn’t finished, and in 1998, Congress passed the Sonny Bono Copyright Term Extension Act of 1998, which lengthened copyrights for works created on or after January 1, 1978 to “life of the author plus 70 years,” and extends copyrights for corporate works to 95 years from the year of first publication, or 120 years from the year of creation, whichever expires first. Once again, Mickey Mouse’s protection was extended.  Now, he will come out of copyright in 2023.  Hang on, that’s just around the corner!  What will Disney do now?  “Disney would not possibly allow its most famous character to go into the public domain, would it?  Although no one can be certain, if the past is any indication of the future, we can expect that Disney will, assuming they have not already, ramp up the lobbying effort and try to get Congress to pass additional legislation to extend its Mickey Mouse copyright. Whether or not this happens, it is indisputable that Mickey Mouse’s effect on United States copyright law has been profound.” [vii]

A cynic might say this is all about business.  Strangely enough, businesses seeking to protect their IP do not have to rely on patents nor copyright, as there are other well-established ways in which protection can be ensured.  Leaving on one side trademarks (registered or not), two key approaches are to use trade secrets and confidentiality agreements.  These are very effective.  If you have signed to respect a trade secret, or a non-disclosure agreement to cover commercial-in-confidence information, telling a third party is a clear-cut case of default.  Such clarity is hard to obtain in claims over copyright and patents, where company lawyers can keep a dispute running for years.  Many companies prefer sharing, but only with those bound to keep things secret.

Should we abandon most existing IP law?  Critics of intellectual property point at evidence intellectual monopolies are harming health (as in the case pharmaceutical patents), preventing progress, and argue that the public interest is harmed by ever-expansive monopolies with copyright extensions, and software or business method patents.  They argue for policies to encourage the diffusion of ideas, including modifying patent laws to encourage competition and to encourage innovation. [viii]  Others simply argue the current system is fundamentally unjust. [ix]

I can every reason to return to the original basis for patents, overthrowing recent decisions.  But there’s a problem: it’s a Supreme Court seemingly beholden to corporate greed and Republican lawmakers.  Darn.  Even so, surely genetic material should not be patentable, however tweaked?

What about copyright?  Here, the possibility of change is real, restoring reasonable ‘economic incentives’ without building long lasting walls over 100 years or more.  That makes no sense.  Many support the Open Access movement, and Creative Commons, a nonprofit “dedicated to building a globally-accessible public commons of knowledge and culture … [which makes] it easier for people to share their creative and academic work”, including free use of work funded by government. [x]  I, like millions of others, use Creative Commons licenses, offering reasonable but limited protection for what I write: even best-seller writers can use the approach, as most of their rewards come within 2-3 years of publication.  If the choice is to share or not to share, it shouldn’t be an issue.  Quite obviously we should share and ensure we all benefit and learn!

[i] https://www.wipo.int/about-ip/en/

[ii] My emphasis.  See https://en.wikipedia.org/wiki/Intellectual_property.  Trademarks can be retained in perpetuity.

[iii] Ibid.  Sorry about all the quoting, but I can’t improve on these comments.

[iv] As in much else in this blog, I am avoiding complicating detail:  for example, there are exceptions to this rule for employees under common law rules in some jurisdictions, and employees in some countries have statutory rights

[v] Actually, cDNA is created naturally, by viruses. Guo J (2013) The Supreme Court revealed its ignorance of genetics. See http://www.newrepublic.com/article113476/supreme-court-genetics-ruling-reveals-judges-ignorance

[vi] S D Bergel, Patentability of human genes: the conceptual differences between the industrialised and Latin American countries, Journal of Community Genetics, 2015 Jul; 6(3): 321–327

[vii] J H Escovedo, Disney’s Influence on Unites Sates Copyright Law, 17 February 2016, The IP Law Blog

[viii] See the extensive discussion of these issues at  https://en.wikipedia.org/wiki/Intellectual_property

[ix] See Intellectual Property and Theories of Justice, ed. Gosseries, Marciano and Strowel, Palgrave McMillan 2008

[x] https://en.wikipedia.org/wiki/Open_access; and https://creativecommons.org/about/