POSTSCRIPT: SCIENCE IN THE FUTURE TENSE

In every generation, science and medicine are challenged to make genuine progress in a way that truly serves humanity. Success in medical science depends on a hierarchy of interests that starts with the physical and emotional suffering of individuals and their families who deserve compassionate care. Step higher and you encounter ways that communities can be served through sanitation, safe food supplies, immunizations, and other prevention strategies. Science should make all the baseline efforts of care and prevention better, and more effective, while limiting unintended negative outcomes.

Unfortunately, the frontier quality of some research can make it impossible to see that a new medicine or technology comes with risks. Radiation used for the diagnosis and treatment of some diseases was not known to cause malignancies until they had already occurred. More commonly, as you’ve read in these pages, promising therapies turn out to be less useful than initially imagined. However, these disappointments should not discourage us entirely. In oncology, for example, some treatments that disappoint after appearing to be breakthroughs still work for just a small number of patients with specific genetic mutations. Patients who are diagnosed with the same general kind of cancer but fall outside this subgroup may feel devastated by this twist of fate. But those who occupy the thrilling sweet spot are certain that all the effort to develop the therapy was more than justified.

In the biological age, when genomic sequencing is becoming routine, we have reached a point where most cancers can be screened for mutations. This practice is now routine at major medical centers and is making its way to community hospitals and oncology clinics nationwide. Similar screening is now possible for a variety of diseases and has improved both diagnosis and treatment in dramatic ways. For example, in a recent positing on a popular website called The Mighty, a young woman who had lived for two decades with a diagnosis of cerebral palsy recounted how genetic screening determined she had a different disorder—dopa-responsive dystonia—that could be treated with a single medication. She took the pills and began to walk unassisted, a day later.

Dramatic success stories are not the norm, but they become more possible with inexpensive gene sequencing and as we get better at processing huge amounts of data. The information I’m talking about is collected every day, in billions of bits, as people move through the health care system, track their fitness on wearable devices, manage their diabetes with finger-stick tests, and complete electronic health diaries.

As of 2017, far too little of this data is being scooped up, organized, and used in an effective way. However, efforts are being made to correct this problem. In 2015 the government launched the Precision Medicine Initiative Cohort Program, which will enroll one million people in a program that will collect biological samples for genetic testing and medical histories. Individuals will, of course, be notified if something is discovered in their samples. However, the main purpose of the project will be to provide research fodder for scientists studying a huge range of health issues. Organizers believe they will discover relationships between environment and various conditions, and, perhaps, identify diseases that appear connected. They also expect the project will establish the basis for trials of targeted drugs by creating groups of people with relevant genomes and helping scientists locate and work with them

Experts who collect and manage billions of pieces of information refer to it, generally, as Big Data. Big Data, and, to be more precise, the ability to process Big Data, causes excitement because it allows us to act with more knowledge and less guesswork. Genetic testing can determine which people will respond to a special drug and which will not. This is what it meant by the term “precision medicine.” Many tech companies are moving into this field with huge investments. IBM’s “Watson,” which is an advanced artificial-intelligence technology, has been adapted to provide information about treatment options to breast cancer patients who submit their genetic information.

An aid and not a replacement for doctors, Watson was found to closely match so-called tumor board recommendations when tested by a big health care system in Bangalore. IBM is also using Watson to check medical imaging results and other test results to uncover diseases that have been overlooked. Beyond oncology, IBM is looking at using Watson to read imaging and consult medical records to find patients who may have early-stage heart disease or be vulnerable to stroke and certain types of eye disease or neurological conditions. Intel is working on a project called All in One Day, which will give cancer patients both a genetic profile of their malignancies and a plan of treatment within twenty-four hours of their diagnosis. The target price for the service is $1,000. Today this process can take weeks or even months, and costs much more.

For high-level science, the next step in Big Data could involve liberating information to serve more purposes. Right now, academic scientists, private laboratories, pharmaceutical companies, and others feel enormous pressure to protect the information they collect in order to maximize the reward for all their hard work. To some extent the incentives to keep this work secret make sense. Who would invest all the time and money required by science if someone else can come along and capture the benefits? However, if there’s one thing that was learned from the human genome project it was that people working together, in an open-source way, can push science along very rapidly. The key to encouraging this pace will lie in maintaining the kind of incentives that drive people to create while opening up avenues of collaboration.

In medicine, the challenge of information overload will grow greater every year. Managing may well involve technologies that allow us to monitor patience remotely, leaving much of the routine work to some form of artificial intelligence. I’m not saying that doctor robots will be taking over, although we will become more reliant on some forms of computing. Instead, we will depend on sophisticated algorithms, which will improve on their own as data grows. This technology will tell us how people respond to medications taken in different doses, at different points in their illness, and under varying conditions of stress. Inputs on diet and exercise could change our understanding of how drugs are metabolized.

The great potential available to us with a rapidly expanding knowledge base and biologically precise therapies, many of which will leverage the power of the immune system, suggest a future rich in possibilities. The promise also calls upon us to embrace the guidance available, not in technology or biology, but in the humanities. Using what we are discovering is going to require an ethic that takes into consideration the value of each human being and the recognition that we all deserve care and cures. Recent research has turned up the fact that in America, one’s health can depend on where you live, right down to a particular neighborhood in a city or town. A recent decline in the life expectancy of middle-class whites in America, driven mainly by stress-related issues—substance abuse, mental health crises—tells us that it’s not enough to develop treatments to target organic illnesses. We must attend to the human spirit along with the body and this requires respect for the human experience.

Science in the service of society will give us medicine that is also just. My experience in both communities—those of caregiving and research—give me hope in this regard. Almost no one takes up either without the desire to see suffering reduced and health increased across communities, nations, and the globe. This improvement, in all our lives, is the future we will realize. And it is coming fast.