Gender failings put half of science talent at risk


Liliam Álvarez Díaz, secretary of the Cuban Academy of Sciences and a member of the Academy of Sciences for the Developing World.

Liliam Álvarez Díaz, secretary of the Cuban Academy of Sciences and a member of the Academy of Sciences for the Developing World. Copyright:

Speed read

  • Liliam Álvarez Díaz is secretary of the Cuban Academy of Sciences
  • She authored the book Be a female scientist or die trying
  • She became interested in gender due to the imbalances she saw

CIf science fails to take advantage of girls who are graduating, it is wasting 50 per cent of the available talent, according to Liliam Álvarez Díaz, secretary of the Cuban Academy of Sciences and a member of the Academy of Sciences for the Developing World.

She is a staunch defender of the value of so-called hard sciences in development and has a PhD in physical and mathematic sciences, and in 2016 published the book Be a female scientist or die trying. SciDev.Net asked her how to tackle some of the challenges faced by women in science today.

What was it like studying physics in Cuba in the 1970s?

When I climbed the steps of the University of Havana in 1968 and enrolled in physics, it was like a challenge. The second year I realised that I should have studied maths because I was doing much better in maths-related subjects. But, a diligent girl with a conservative spirit, I said: “I started physics, I’ll finish physics.”

What was the context? Were you the only woman?

No, there were other girls. Those years were very interesting. You enrolled in what you wanted. There were no entrance exams. There was a wonderful student residence. It was a great privilege. In the first class of physics, there were more than 100 students in a huge classroom. When we finished there were only 25 of us. At that time nobody talked about gender.

What is your research area about? How is it related to applied science?

In many spheres of science, many phenomena are modelled with mathematical equations. For example, how is the hurricane path calculated? With equations. How was the dome of the Sports City, in Havana, calculated? It was the work of civil engineers, with a mathematical model.

Calculations of differential equations are applied to meteorology, chemical kinetics. For example, if you inject a drug, how is it going to distribute inside the organism? That is kinetic, and it is a system of equations.

liliam alvarez en costa rica.JPG
Liliam Álvarez Díaz with colleagues from a recent Teaching Mathematics Symposium in Costa Rica..

What drew you to studying gender in science?

I got into gender issues in the 1990s because I observed that, not only in Cuba but in the world, there were very few women in physics or mathematics. I am not a gender expert, but I learned what gender is, that is a cultural definition, not given by biology.

I was always interested in the metaphors that experts in gender use, and I started to collect them. The first one: glass ceiling. Gender specialists explain it in a certain way but for me it is something all women face. Above is the power and below is us, and to get there we have to hit that glass ceiling.

What did you achieve in the eight years you worked as director of science?

We transformed national programmes, we opened institutes, which did not exist until then. We did a lot with schools, especially teachers, to promote science, because we realised that the creation of new generations of scientists in Cuba happens through the training of teachers.

We introduced science festivals. We were the pioneers in Cuba of something that already existed in the world: the experience of talking about science to the general public. We filled the Capitol with teachers talking about genomics, protons, and stem cells.

Despite Cuban statistics where women make up more than 50 per cent of parliamentarians, or 63 per cent of the science sector, there are still obstacles. What are they?

First, in general, in daily life. As I meet with my counterparts, scientists from other countries, I see that their daily life is not as difficult as ours.
Second, wages. The standard of living is a great obstacle, not only in your personal life, but as a role model for young girls. You’re competing with successful artists or singers.

What signs of discrimination do you see in the science sector?

They are not very open, but they exist. For example, I had a very pretty student who dressed in short skirts. My colleagues asked why this girl was studying maths instead of dancing at the [Havana cabaret club] Tropicana. That is discrimination.

UNESCO reports that only 35 per cent of people in STEM careers are women. How can this be reversed?

If science does not take advantage of those girls who are graduating, it is wasting 50 per cent of talent.
How can you influence this reality from an early age? You have to design strategies and policies. A Spanish teacher recently told me that she got her girls to write on the theme I do not want to be a princess; I want to be a quantum physicist. I give you this example because we need a strategy from the ministries and then from the media.
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Flying cars coming in five years, says Intel drone chief


Anil Nanduri says it’s cheaper to put cars in the air than under cities in tunnels.

Intel drone leader Anil Nanduri
Intel drone leader Anil Nanduri

 

Drones are useful today for real estate photos and gas pipeline inspections. They could be useful tomorrow for home security and package delivery. But in a half decade, they could well shuttle you to work over the heads of drivers stuck in traffic.

That’s what Anil Nanduri, general manager of Intel’s drone group, expects. Drone innovation combined with people paying their way out of gridlock will mean flying cars will transform from exotic to accepted in the next few years.

Some companies agree, perhaps most notably Ehang and Uber, which wants to launch air taxis by 2023. But there are plenty of safety, engineering and social challenges. Not to mention the fact that Elon Musk — the CEO of Tesla, SpaceX and the Boring Company, who has a knack for figuring out what’s just within our technological reach — thinks we’re better off putting cars in underground tunnels.

Nanduri’s job is closer to today’s tech. He’s trying to automate drone operations such as inspecting bridges for cracks or choreographing constellations of drones in a kind of digital fireworks. The latter is a publicity stunt, most recently on display at Super Bowl 53, but smoothly coordinating 2,000 drones that’re flying up to 8 meters per second is also a dress rehearsal for tomorrow’s more complicated airspace.

Nanduri sat down with CNET’s Stephen Shankland for an exclusive interview at the All About Autonomy 2019 conference. The following is an edited transcript.

Q: Let’s look five years in the future. Do you think we’re going to have flying cars?
Nanduri: There will definitely be flights with flying cars in five years. At scale? Probably not. But definitely you’ll see them starting to be up in the sky. The most amazing thing about autonomous air traffic is that airspace solves the three-dimensional challenge that the ground traffic is faced with.

Watch this: Uber reveals more about its flying taxi ambitions
2:53

What about 10 years? Will it be more common?
Nanduri: In 10 years, you’ll start to see air taxis. It’s our job to make it happen.

A business guy can run the economics and see how the cost models work out at the ecosystem level. When you see that, you know it’s going to happen. And you have these huge pain points. Traffic is only getting more and more congested, and people want instant gratification — they want everything delivered.

Now, how do you put it all together and get the regulations and get the compliance? Once you see that one instance of it working, then you’ll see it rapidly roll out.

I worry about that one instance where you see it not working. People are famous for making decisions based on avoiding negative outcomes.
Nanduri: It’s absolutely something the industry should be cognizant of. A recent example is what happened at the Gatwick Airport [when a drone shut down air traffic]. We got to acknowledge it, embrace it. And we need to know that technology can solve it. It slows it down, but because the economics and the pain points are there, it will eventually cross that barrier.

Intel Shooting Star lantern-equipped drone
One of the 150 Intel Shooting Star lantern-equipped drones used in Super Bowl 53’s half time show.

Stephen Shankland/CNET

When an ordinary car has a problem at 60 mph or 30 mph, it’s still stuck to the ground. With flying cars you have this problem called gravity. Is that something you can overcome?
Nanduri: You have 40,000 people per year who die in car accidents. Yet people accept it, and they drive. When you have two hours stuck in traffic and you can shorten that, especially in commuting, you have to adapt. If you go today to Bangalore or Beijing, it’s so congested, you are literally in a parking lot.

Once you see [flying cars], the benefit far overrides the hurdles. If I give you two hours back, you get to watch that movie or spend more time with your family.

They have to be safe. There are always early adopters willing to take bigger risks. But as time progresses, more and more people will get comfortable.

Three dimensions gets you a lot more room than being confined to the surface of the Earth. Elon Musk [head of Tesla, SpaceX and the Boring Company] wants to build tunnels under Los Angeles and Las Vegas. What do you think of tunnels for cars?
Nanduri: It’s very simple. It’s a cost. Putting it into the sky is lot less expensive than having to touch physical infrastructure.

The same thing goes with the cost of deploying fiber versus wireless communication. That’s why 5g is so much more exciting. I can get, you know, the huge bandwidth without the expensive infrastructure costs of laying out cables.

Where will we see the first use of passenger drones? The worst gridlock is in urban areas already crowded with news helicopters, skyscrapers and maybe delivery drones.
Nanduri: It’ll come from different avenues. There are always gonna be the entrepreneurs and high-net-worth people who can showcase the new technology.

I think there will be cargo drones moving supplies and equipment — that will drive a lot of the innovation. You may be not even surprised if the initial versions of these will have a pilot in there, just to give that sense of safety. It will evolve from being manned to eventually becoming unmanned.

You get a half an hour of battery life out of little camera drones weighing 100 grams. What about when it’s 100 kilograms of human payload?
Nanduri: You hit on the biggest challenge. If you look at the physics of a multirotor system, no matter what size and scale, you’re going to have 30 to 45 minutes of battery life with existing battery technology. With a larger drone, you can put more battery in it, but you’re carrying more weight. That’s why people are looking at hybrid EVTOL [electric vertical takeoff and landing] systems. They can take advantage of the aerodynamics of tilt-rotor designs. Once you are in flight, you’re more like a traditional aircraft, but then you’re able to take off and land vertically. That has its own challenges, so you see a lot of innovation to extend your flight time.

Intel is hoping others will adopt its scale for drone autonomy, similar to one already used to grade self-driving car abilities.
Intel is hoping others will adopt its scale for drone autonomy, similar to one already used to grade self-driving car abilities.

Intel

Even little tiny quadcopters can get pretty noisy. If you’re talking about something big enough to lift a human being or big Amazon packages, with multiple flights a day to your neighbors’ houses, that really adds up.
Nanduri: It’s all social acceptance and social perception that’s going to drive it. It’s more important as they come into the urban, high-density areas. But is it really the loudness? You’ll be surprised — sometimes it’s the frequency of the sound.

Does “social acceptance” translate to “better get used to it”?
Nanduri: No! There is technology that will help make them quieter. If it’s a frequency problem, it’s how the rotors are designed that gives you the changes in the frequency tones. There’s research going on as to how I can make them more human friendly. These things become barriers to adoption. But at end of the day, the social acceptance comes down to value. If people see value, then they’re willing to deal with some of the irritating aspects that come as part of that.

Will we have landing pads at our houses and apartments and put giant QR codes on our roofs to help drones navigate to our homes?
Nanduri: It could be a mat with a QR code on it. But to be more seamless, depth-sensing sensors will map the environment. They’ll enable the systems to get very smart, to know even if there’s a pet in the backyard so they know not to land. The takeoff and landing elements and the safety around that are still things we’re learning. When do I land? Is it safe to drop a package? Do I land and then someone picks it up?

In the old days, we didn’t have mailboxes, and now we do. Will everybody have drone mailboxes?
Nanduri: It’s going to vary. You could say, I’m having a picnic in the park and I want my pizza delivered here. There’s not going to be an automated spot, but the system should be capable of knowing where is it safe and get it to me. You don’t have to be constrained to a location to get what you need.

Chemotherapy Myths and Misconceptions


 

Chemotherapy has long been a mainstay of cancer treatment. But a lot has changed since Sidney Farber, MD, the founder of Dana-Farber Cancer Institute, achieved the first remissions for pediatric leukemia using chemotherapy in the 1940s.

Today, in the era of precision cancer medicine, there are newer treatments and chemotherapy that can more specifically target cancer cells. Researchers have also discovered the effectiveness of using chemotherapy drugs in conjunction with other drugs to pack a more powerful punch. To put it simply: Chemo is a lot better today than it used to be.

Still, there’s a lot of misinformation surrounding this kind of cancer treatment. In this episode, we explore some of the most common myths and misconceptions with Clare Sullivan, MPH, BSN, clinical program manager for Patient Education at Dana-Farber.

Transcript

MEGAN RIESZ: So, first, can you just kind of explain generally what chemotherapy is and how it’s commonly administered?

CLARE SULLIVAN, NPH, BSN: Sure. Think about what the body does. The body is made up of cells that normally divide and grow and are replaced. Think about how your fingernails grow. Chemotherapy (or chemo, for short) is a group of medicines or drugs that treat cancer and other diseases. Cancer also divides and replicates.

Different chemotherapy drugs act in various ways. Some chemotherapy drugs can kill the cancer as they divide at critical times during the cell cycle, something that we learned way back in high school. Some chemotherapy can target the cancer’s food supply and kill important hormones and other nutrients it needs to grow. And then some chemotherapies can target the cancer’s genes and prevent it from growing. Then, one of the other interesting areas is that some chemotherapy can prevent the tumor from growing new blood vessels that it needs to grow and spread.

There have been many new and exciting developments in the field of cancer care, and when I say this, I mean chemotherapy, whether you add different combinations or other treatments. So, chemotherapy is still a very important tool for treating many cancers today.

MEGAN: Just to be clear, how is chemotherapy different than immunotherapy, which is something that’s talked about a lot today?

SULLIVAN: Well, immunotherapy has received a lot of attention because of new medications discovered that help treat cancer, but immunotherapy is unlike chemotherapy because of the way that it fights cancer.

Let’s start at the beginning. The immune system is a very complex network of cells and organs that defend against foreign substances, like bacteria or viruses.

Think about when you get a cut. The body’s defenses go into action immediately scanning and will recognize any foreign bacteria and then send out the correct army or navy to wipe out that invader. The immune system is so sophisticated that it can remember that invader, and if it comes again, it will recognize it and protect you from that disease. This is very similar to the chicken pox.

MEGAN: And let’s talk about side effects, which can be big considerations for patients. What are some common side effects that patients experience during chemotherapy?

SULLIVAN: The most common side effects for chemotherapy depend on the drug, the manner it’s given, the dose, and how often you get it, but the number one side effect across the board is fatigue. Then there are a few others that I’ll mention: appetite changes, nausea. But again, remember, there’s a lot of anti-nausea medications that are very effective now. A weakened immune system where you might get bruising or bleeding, and this is because of the way the chemotherapy goes after the cell cycle—it decreases the red blood cell and the white blood cell. Constipation and diarrhea are also another side effect, but again, there are a lot of good medications that are very effective. Then, mouth care—mouth care is really important to prevent mouth sores.

I want to go back to my first symptom, which was fatigue. Fatigue is real. Think about it as tiredness that doesn’t go away with rest. If you take a nap and wake up, you should ordinarily feel refreshed, but fatigue is when you wake up and really feel just as tired as when you went to sleep. So, during your treatment, of course, there will be times that you need to rest, but when possible, the best way to offset a host of issues that can happen when you lay in bed all day is to stay active.

Here are some tips. First, I want to think about those days that you’re most tired, really struggling with fatigue and really just around the house. Every time that you get up to the bathroom, try to move around. Move from the bathroom to the couch for a few minutes to a chair, and then move back to bed and continue that cycle as you get up to the bathroom. Just keep moving. Keep walking, even if it’s around the dining room table and in the middle of the night. If you can carry something like a laundry basket, put some weight in it. If you can carry a carton of milk around the dining room table…something just to help you move. Do some arm or leg stretches when you’re in or out of bed. A tip is that if you’re watching TV, put the exercise channel on and follow along in bed.

On a good day, you’re going to want to put your coat on right over that bathrobe, walk around the block, get a good pair of slippers with some comfortable soles, and you don’t even need to change your shoes.

The tip here for you is that you will find your energy perks up a few days before your next chemotherapy treatment. Use this time wisely. This is when you can really get out of the house. Maybe you might work a half a day. Maybe someone would drive you to work. Maybe you could work around the house. Walk a little further than just around the block. Walk with a little bit of speed. Use your arms. Get off a stop earlier on the train. Take the stairs at work. Take the stairs during your hospital visit. Take the dog for a walk. On your way back, pull a few weeds in the lawn.

If you’re in the hospital and you’re getting your chemotherapy in the hospital, work with the nursing staff on the floor. Measure how many laps it would take around the unit to equal a mile. We have many units over at the Brigham with signs of encouragement for lap walking.

MEGAN: So, patients often wonder if they will lose their hair during chemotherapy. Can you talk about this as well?

SULLIVAN: Sure. There are many other side effects that are specific to the drugs, and the one that I have not mentioned, as you have brought up, is hair loss. Many people associate hair loss with chemotherapy from movies or TV, but this is not as common anymore. When you enter the infusion clinic, you might be surprised to see that many patients have hair. This is not to say that some chemotherapy still causes hair loss, but it is not as common as people think.

MEGAN: So, chemotherapy can be used in a few different ways—curatively or palliative, for example. Can you talk about this?

SULLIVAN: Yes, Megan. What you’re referring to are the three goals of cancer treatment. There are actually three. You may see one of these terms on your initial chemotherapy consent, but most importantly, you may want to confirm with your cancer team what the strategy is for your treatment plan. Starting out on the same page with your team is very important. Remember, this can change as information about your cancer is understood over time by your team.

The three strategies to cancer treatment are cure, control, and palliation. Cure is when the cancer is completely removed, and the intent is that the cancer will not come back. Control would be the second strategy. That’s when disease cannot be fully removed from the body, but the team can keep it in check for long periods of time. Then the third strategy is what we call palliation. The disease here cannot be successfully removed and may not be controlled for long, but the team is confident that they can minimize any symptoms to help you feel more comfortable.

The word “palliation” can be confusing and even turn some people off from the medical specialty of palliative medicine. Palliative care is a specialized medical care for any cancer patient. It helps patients get relief from pain, symptoms, and the stress of having a serious illness. It can help improve their quality of life, no matter what treatment goal there is. Palliative care can help with fatigue, pain, nausea, shortness of breath, and a whole host of other symptoms that you may have during treatment, where the goal of palliative care is to help you feel more comfortable during your treatment, preserve your dignity, and better communicate with your family and caregivers.

Palliative care can be helpful through all stages of cancer care. Early on, it can help make the treatment more tolerable. Later, it can help you with daily life, can assist you in planning your care, and provide you with an additional layer of support. Think of it as a superhero. Think of it as the superheroes of cancer care.

Often, people mix up the word “palliative care” and “hospice care.” Palliative care is available to any patient with any stage of cancer at any age. Hospice care is for patients also receiving palliative care, but hospice care is typically only given during the final months of life.

MEGAN: Is there anything else you might like to convey to patients who are starting chemotherapy?

SULLIVAN: Sure. There are some tips here that I’d really like to share with you today. For those people who might be going to an infusion clinic or going even to a hospital, it’s OK to ask for a tour. Go and visit the infusion area, or even walk through the hospital ward, just to get familiar with the surroundings. Bring a friend and stay active.

If you don’t understand something that the doctor or nurse says, please ask them to repeat. It’s very important that you understand. Know who to call and when. Keep that information near you at all times, whether it be on your refrigerator, in your wallet, or type it right away in your phone contacts the minute that you get it. Make sure family members have it or close friends know where this information is kept.

Doudna’s Confidence in CRISPR’s Research Potential Burns Bright


Jennifer Doudna, one of CRISPR’s primary innovators, stays optimistic about how the gene-editing tool will continue to empower basic biological understanding.
 

Portrait of Jennifer Doudna

Jennifer Doudna, one of the inventors of CRISPR genome editing technology, outside her laboratory and the Innovative Genomics Institute she founded at the University of California, Berkeley. “If you had told me 10 years ago that bacteria had evolved proteins that could be programmed to find and cut any DNA sequence,” she said, “I would have just laughed.”

Jana Ašenbrennerová for Quanta Magazine

No one needs to remind Jennifer Doudna about the power of CRISPR, the precision genome-editing technology she codeveloped. CRISPR “gives us a way to ultimately control the evolution of any organism — including ourselves. It is a profound thing. Human beings have now learned enough about our own genetic code that we can change it at will,” she said. “It’s kind of crazy to think about.”

That’s why when reports emerged last November that the scientist He Jiankui of the Southern University of Science and Technology in Shenzhen, China, had used CRISPR to alter the DNA of twin baby girls — crossing a line that genetic engineers had respected for decades and reaffirmed in 2015 — Doudna was quick to speak out. Describing herself to the media as “horrified and stunned,” she criticized his actions as risky, premature and unnecessary, given the absence of pressing medical need for the children to be modified experimentally. She encouraged the international scientific community to develop better guidelines for permissible genome editing in humans.

CRISPR technology makes genome editing temptingly simple because it allows scientists to cut and edit sequences of DNA in any species, including humans, at will. It was inspired by a long-overlooked defense mechanism with which many bacteria fend off viruses: By inserting fragments of viral DNA into specialized structures in their own genome (the “clustered regularly interspaced short palindromic repeats” that give CRISPR its name), bacteria provide their daughter cells with a way to recognize and quickly rebuff future invasions by similar viruses. Doudna and Emmanuelle Charpentier of the Max Planck Institute for Infection Biology in Berlin showed in 2012 that the bacterial system could be adapted as an editing tool. (Several other scientists, including Feng Zhang of the Broad Institute and Virginijus Šikšnys of Vilnius University are also credited with contributing to CRISPR’s development, and multiple patent lawsuits surround the ownership of the intellectual property.)

But although Doudna argues for caution when contemplating changes that could be passed down for generations, she remains a forceful advocate for the potential of CRISPR in basic research, as well as its medical and biotech applications. “I think when you understand how things work, you can apply them more effectively. And once you apply them, you invariably uncover things that you didn’t understand about the fundamental biology of that system,” Doudna said. “I love that kind of interplay.”

Quanta Magazine sat down with Doudna, a professor of chemistry and molecular and cell biology at the University of California, Berkeley, to discuss how CRISPR is furthering basic biology research. That interview and subsequent exchanges have been condensed and edited for clarity. 

When CRISPR is discussed in the public, it’s often in regard to how it will be used to cure and treat disease. How do you think CRISPR has and will further basic biology research?

I’ll give you two examples that I think are fun because they illustrate some of the creative things people are doing now that weren’t possible in the past. One of them is a project to investigate the origins of bipedalism. This project involves comparing the genetics of two types of rodents — a standard quadruped mouse and a rodent called a jerboa that hops on its hind legs, so it’s bipedal.

What if I start putting genes from the bipedal rodent into the other rodent? Can I eventually make a bipedal field mouse? This is the kind of project that’s possible now with CRISPR.

The other CRISPR experiment I want to highlight explores the content of the Neanderthal genome. A lot of us now know that we have a little bit of Neanderthal DNA in our background, but what were the real differences between modern humans and Neanderthals? Why did Neanderthals go extinct, and what can that tell us about our own evolution?

PHOTO: Doudna holding a crispr model

Doudna holds a model of a CRISPR-Cas9 complex beginning to edit a stretch of DNA (blue). The CRISPR’s guide RNA (orange) binds to the defined DNA target; the Cas9 enzyme (white) cuts the DNA.

Jana Ašenbrennerová for Quanta Magazine

How do you explore that?

An experiment that’s now underway is taking genes from the Neanderthal genome and putting them into human cells that are cultured in the lab in the form of brain organoids. Organoids are balls of tissue that form organlike structures in a laboratory dish. I don’t want to say they’re like little brains, but these organoids have some properties of collections of neurons found in the brain.

The question then is to ask, if you start introducing Neanderthal specific genes into these human brain organoids, what happens? What kinds of changes do we see physiologically in those cells and in those balls of tissue? Can we learn something about the genetics of neuronal development in Neanderthals that might be different from what happens in humans?

It’s the early days of this research, and an organoid is not the same thing as a brain, so there’s going to have to be some interpretations of what the data mean, but I think that’s the kind of experiment that couldn’t have been done before.

Why not?

For the most part, we didn’t have a way to introduce changes to genomes precisely. The way that gene therapy was done originally was using viruses that integrate into human DNA, but the viruses integrate where they want to go, not necessarily where you want to make a change to the DNA.

Earlier technologies for gene editing were also very difficult to use in many settings. They required a lot of legwork to develop, like engineering particular proteins for each desired change to a genome. Certainly, it was difficult with those technologies to make more than one change at a time. With CRISPR, experimenters can change multiple genes in a genome in one shot.

Do you think that the medical applications of CRISPR in themselves can inform basic science?

For sure. CRISPR technology has been widely adopted by all kinds of scientists, including people like me. I was never doing anything with genome editing before CRISPR came along.

In my lab we’ve had a project over the last few years working on Huntington’s chorea, a degenerative neurological disease. The mutation that causes the disease is a single codon — three base pairs in the DNA — that gets repeated many times. If the codon gets repeated too many times, it leads to a defective protein that causes this disease. That’s been known for a long time, but the challenge was, how do you fix it?

We’ve been working on a way to deliver the CRISPR into mouse neuronal cells to make the necessary edits. But one of the curious things that’s come out of that line of work is that we found that only neuronal cells in the mouse brain were getting edited, not [the supportive glial] cells called astrocytes.

These cells are a lot smaller, so it could be that they don’t have enough surface area to take up the CRISPR protein efficiently. Or maybe they don’t respond to DNA cutting and editing in the same way as other cells.

Jennifer Doudna, one of the coinventors of CRISPR technology, discusses how her work on bacterial defenses against viruses helped lead to a discovery with a revolutionary impact on biological research.

Video: Jennifer Doudna, one of the coinventors of CRISPR technology, discusses how her work on bacterial defenses against viruses helped lead to a discovery with a revolutionary impact on biological research.

Jana Ašenbrennerová for Quanta Magazine

So not all the cells in the brain respond to the CRISPR treatment the same way.

We also found that, when we inject CRISPR molecules into one place in the mouse brain, we see cells that are a fair distance away from the injection site also get edited. That was a surprise because it suggests there’s some way of trafficking molecules through the brain to areas that are not right next door to where the needle goes in.

Is there some mechanism for molecular trafficking in the brain that hasn’t been appreciated? That’s a very fundamental question in biology. That takes us back to asking, “Gee, how does the brain work?” Now we’re exploring answers to these questions.

I have to say that this example from my lab is emblematic of what’s going on in a variety of labs. CRISPR enables very applied experiments, but these experiments raise very fundamental questions that you have to go back and address.

How pervasive do you think the use of CRISPR will become in biology? It already seems to be everywhere in biomedical labs. Do you think there might be applications in fields like ecology, for example?

Absolutely. It depends on your definition of ecology, but some of the early adopters of the CRISPR technology were people who were trying to understand the genetics of butterfly development. Having a tool that allowed the manipulation of genes in non-model organisms — organisms that scientists haven’t been working on for decades in the laboratory but instead collected in the wild — opens up the possibility of real experimentation in a way that previously was not possible.

Effectively any organism becomes a model organism — a genetically tractable system for doing experiments. We joke in the lab that we’re turning humans into yeast: In the past, you had to do experiments in yeast or fruit flies and then infer what those data meant about human cells. You couldn’t easily manipulate human cells genetically to understand genetic function. Now, with CRISPR, you can.

CRISPR was first discovered as a defense mechanism that bacteria use against viruses. Do you think other new research tools might come from other discoveries about bacteria?

I suspect so. If you look at the technologies that have come along over the last several decades — polymerase chain reaction for amplifying DNA, molecular cloning — they all came about from studying how microbes fight off viruses or respond to stimuli.

We also know very little about the bacterial world right now. There’s a huge number of organisms that have never been identified by scientists or cultivated in the laboratory, and they surely have interesting biology associated with their lifestyles. As more of those organisms are studied and identified, I have no doubt that we’ll find things that will lend themselves to new technologies.

PHOTO: Doudna walks in her lab

Doudna walks through her lab in the Energy Biosciences building on the Berkeley campus.

Jana Ašenbrennerová for Quanta Magazine

Are there any particular enigmas in bacteria that you have a hunch might lead to some sort of research tool?

That’s always hard to predict. That being said, I’ll give you an example of an interesting phenomenon: the discovery of this new category of bacteria that are incredibly small. It’s a whole new phylum of organisms — they’re currently called the candidate phyla radiation (CPR) bacteria. They almost challenge the notion of what’s a cell and what’s a virus.

A lot of these organisms probably grow symbiotically with other bugs, sharing important molecules, maybe even the building blocks of DNA, RNA and proteins. But how do they import molecules? How do they control their environment so that other kinds of bacteria don’t overgrow and crowd them out?

These are all unanswered questions. We don’t understand anything about their fundamental biology in a molecular sense. Will answers to these questions lead to a new technology? I don’t know, but it’s certainly going to lead to interesting biology.

So, the place to look for new research tools might be organisms that are atypical, so to speak?

But how do you define atypical? There’s this old Steve Forbert song: “It’s often said that life is strange … but compared to what?”

These tiny CPR bacteria are the ones in which you and Jillian Banfield of the University of California, Berkeley recently found new Cas enzymes [for cutting strands of DNA] that could be used with CRISPR technology, aren’t they? What makes those Cas enzymes potentially so interesting and useful?

One of the new enzymes we identified is called “CasX.” It’s particularly interesting because it seems to work quite differently from its cousin Cas9, the enzyme that many conventional bacteria use in their CRISPR defenses and that’s commonly used in CRISPR technology. But a few core ingredients are the same. This gives us insight into the basic recipe for CRISPR cutting proteins. The more we understand these proteins, the better we can engineer them. CasX is also appealing because it’s much smaller than Cas9, which might make it easier to slip into cells for therapeutic genome editing.

There have also been other new spinoff technologies developing out of CRISPR-Cas9, like CRISPR-GO, DNA imaging and anti-CRISPR. How might they help basic biology?

So let’s just go through those. CRISPR-GO is this clever way of using CRISPR enzymes to bring particular parts of the genome into physical proximity. There’s evidence that when genes are being expressed together in cells, they’re often brought together physically to the same location in the cells, and that can fundamentally affect the levels of proteins that are produced from certain genes. What CRISPR-GO does is provide a technology for doing that kind of physical tethering, except now the scientists can control it rather than the cell controlling it. I think that creates an opportunity to start dissecting the relationship between the 3D architecture of the genome and the communication between genes, and the resulting levels of proteins or RNA molecules that are made from those genes. So that’s exciting. It’s something that, again, really hasn’t been possible before, to control the 3D architecture of chromosomes and ask how that affects the output from the genome.

You mentioned DNA imaging. The idea there is what’s being referred to as “chromosome painting,” where you can program the CRISPR-Cas9 protein to bind and basically sit for extended periods of time at certain places in the DNA. You can decorate the CRISPR-Cas9 protein with different colors of dyes to light up a particular gene or section of a genome, even an entire chromosome, by just tiling it with these little RNA-protein complexes. So it’s a method for imaging.

In the case of anti-CRISPR, these are teeny tiny natural proteins involved in regulating CRISPR systems. You can imagine that in bacteria that are getting infected by viruses, over time viruses have evolved ways of avoiding being taken out by CRISPRs, and one of the ways they do that is using these little inhibitors called anti-CRISPRs. There’s interest in these because of the potential to control gene-editing outcomes — using these kinds of proteins to turn off gene-editing proteins in cells to protect the genome from being modified in unintended ways. There’s a whole line of research now that’s taken off to look at natural regulators and inhibitors of CRISPR pathways and ask whether those can be harnessed for technology purposes.

Could the development of anti-CRISPR quell fears about genome editing in humans or other organisms, if we had an off switch to throw if CRISPR-Cas9 wasn’t working as intended?

That’s exactly what people are thinking about. In fact, there’s a whole program funded by DARPA (the U.S. Defense Advanced Research Projects Agency), that has the title “Safe Genes,” that’s about safe ways of manipulating genes and genomes. And one of the strategies that groups are using to do that is using these anti-CRISPRs.

Do you think that CRISPR helps us get closer to understanding how all the pieces in cells are working together rather than just separately?

I think it will increasingly play that kind of a role in the future.

Let’s go back to neuroscience, because there’s a case where CRISPR has come to the fore in studies of the development of the brain. Researchers haven’t been able to figure out how many different types of cells are in the brain. We also don’t know how the brain develops in the sense of its 3D architecture. If you start with a stem cell or a few stem cells, how does that develop into an entire brain, and what’s the map of the brain?

There’s a lot of interest right now in using CRISPR to do what’s called lineage mapping. If you have a population of cells that develop from a single cell or a small collection of cells, you can track how cells from that starting population give rise to their progeny by introducing a little edit to their DNA to mark them.

Several research teams are using CRISPR this way to figure out where these daughter cells end up in the brain and even what kinds of cells they become. I think these kinds of experiments will lead to a more fundamental understanding of tissue development — in particular, in the brain — that hasn’t been possible before.

That does sound promising.

I’ll give you another example. There are interesting cases — and we’re finding more and more of these as people get their DNA sequenced — of families in which everybody has a certain allele, a certain DNA sequence of a gene, but only some of them have a disease that’s associated with that allele. The others don’t. So you know that there’s something in the DNA of the people who are unaffected that suppresses a negative impact of that gene and makes them not susceptible to cancer or whatever other disease they would otherwise succumb to. What are those suppressors?

I think understanding those kinds of genetic interactions is going to be incredibly powerful going forward. Up until now, we haven’t really had a way to do it because, first of all, people weren’t widely going around sequencing their genomes. That’s starting to happen more and more, with companies that offer this and the cost coming down. Then there’s also having a technology that allows genetic manipulation of patient-derived cells. So if you have somebody that comes into a clinic and they have a disease that gets diagnosed, you can take cells from that person and you can cultivate them in the lab. That’s been possible for a while, but what wasn’t possible previously was to do genetics on those cells. Now we can, in living cells that relate to an actual patient.

That sounds like an unexpected benefit of the sequencing technology.

I always like to point out that there’s a certain serendipity to science. It’s wonderful, but it also means that you can’t predict outcomes. CRISPR technology is a great example of that. If you had told me 10 years ago that bacteria had evolved proteins that could be programmed to find and cut any DNA sequence, I would have just laughed. I would have been like, “Yeah, that’s definitely science fiction.”

I think it’s important for people to appreciate that this is how a lot of science happens.

A Nobel Prize-winning psychologist says most people don’t really want to be happy


We think we want to be happy. Yet many of us are actually working toward some other end, according to cognitive psychologist Daniel Kahneman, winner of the 2002 Nobel Prize in economics.

Kahneman contends that happiness and satisfaction are distinct. Happiness is a momentary experience that arises spontaneously and is fleeting. Meanwhile, satisfaction is a long-term feeling, built over time and based on achieving goals and building the kind of life you admire. On the Dec. 19 podcast “Conversations with Tyler,” hosted by economist Tyler Cowen, Kahneman explains that working toward one goal may undermine our ability to experience the other.

For example, in Kahneman’s research measuring everyday happiness—the experiences that leave people feeling good—he found that spending time with friends was highly effective. Yet those focused on long-term goals that yield satisfaction don’t necessarily prioritize socializing, as they’re busy with the bigger picture.

Such choices led Kahneman to conclude that we’re not as interested in happiness as we may claim. “Altogether, I don’t think that people maximize happiness in that sense…this doesn’t seem to be what people want to do. They actually want to maximize their satisfaction with themselves and with their lives. And that leads in completely different directions than the maximization of happiness,” he says.

In an October interview with Ha’aretz (paywall), Kahneman argues that satisfaction is based mostly on comparisons. “Life satisfaction is connected to a large degree to social yardsticks–achieving goals, meeting expectations.” He notes that money has a significant influence on life satisfaction, whereas happiness is affected by money only when funds are lacking. Poverty creates suffering, but above a certain level of income that satisfies our basic needs, wealth doesn’t increase happiness. “The graph is surprisingly flat,” the psychologist says.

In other words, if you aren’t hungry, and if clothing, shelter, and your other basics are covered, you’re capable of being at least as happy as the world’s wealthiest people. The fleeting feelings of happiness, though, don’t add up to life satisfaction. Looking back, a person who has had many happy moments may not feel pleased on the whole.

The key here is memory. Satisfaction is retrospective. Happiness occurs in real time. In Kahneman’s work, he found that people tell themselves a story about their lives, which may or may not add up to a pleasing tale. Yet, our day-to-day experiences yield positive feelings that may not advance that longer story, necessarily. Memory is enduring. Feelings pass. Many of our happiest moments aren’t preserved—they’re not all caught on camera but just happen. And then they’re gone.

Take going on vacation, for example. According to the psychologist, a person who knows they can go on a trip and have a good time but that their memories will be erased, and that they can’t take any photos, might choose not to go after all. The reason for this is that we do things in anticipation of creating satisfying memories to reflect on later. We’re somewhat less interested in actually having a good time.

This theory helps to explain our current social media-driven culture. To some extent, we care less about enjoying ourselves than presenting the appearance of an enviable existence. We’re preoccupied with quantifying friends and followers rather than spending time with people we like. And ultimately, this makes us miserable.

We feel happiness primarily in the company of others, Kahneman argues. However, the positive psychology movement that has arisen in part as a result of his work doesn’t emphasize spontaneity and relationships. Instead, it takes a longer view, considering what makes life meaningful, which is a concept that Kahneman claims eludes him.

Kahneman counts himself lucky and “fairly happy.” He says he’s led “an interesting life” because he’s spent much of his time working with people whose company he enjoyed. But he notes that there have been periods when he worked alone on writing that were “terrible,” when he felt “miserable.” He also says he doesn’t consider his existence meaningful, despite his notable academic accomplishments.

Indeed, although his contributions legitimized the emotion as an economic and social force and led to the creation of happiness indices worldwide, the psychologist abandoned the field of happiness research about five years ago. He’s now researching and writing about the concept of “noise,” or random data that interferes with wise decision-making.

Still, it’s worth asking if we want to be happy, to experience positive feelings, or simply wish to construct narratives that seems worth telling ourselves and others, but doesn’t necessarily yield pleasure. Meet a friend and talk it over with them—you might have a good time. 

Visions of a Better World


Noam Chomsky, Richard Dawkins, Martin Rees and others answer the question: What’s your utopia?

Visions of a Better World

Unless you are too stoned or enlightened to care, you are probably dissatisfied with the world as it is. In that case, you should have a vision of the world as you would like it to be. This better world is your utopia. That, at any rate, is the premise of a question I’ve been asking scientists and other thinkers lately: What’s your utopia?

I presented students’ responses to this question last year. This final column for 2018 (if aliens land in Central Park or CERN discovers a portal to a parallel universe, I’ll let major media handle it) offers responses from scientists and others I’ve interviewed lately. My hope is that these visions will cheer up readers bummed out by my previous post, “Dark Days.” See the end of the post for my utopia.

Noam Chomsky: I don’t have the talent to do more than to suggest what seem to me reasonable guidelines for a better future.  One might argue that Marx was too cautious in keeping to only a few general words about post-capitalist society, but he was right to recognize that it will have to be envisioned and developed by people who have liberated themselves from the bonds of illegitimate authority.

Richard Dawkins: My utopia is a world in which beliefs are based on evidence and morality is based on intelligent design—design by intelligent humans (or robots!). Neither beliefs nor morals should be based on gut feelings, or on ancient books, private revelations or priestly traditions.

Sheldon Solomon: Staying alive long enough to see that my children are relatively settled and economically secure and knowing that there’s a decent chance that the earth will not be reduced to a festering heap long before the sun explodes!

Sabine Hossenfelder: That we finally use scientific methods to restructure political and economic systems. The representative democracies that we have right now are entirely outdated and unable to cope with the complex problems which we must solve. We need new systems that better incorporate specialized knowledge and widely distributed information, and that better aggregate opinions. (I wrote about this in detail here.) It pains me a lot to think that my children will have to live through a phase of economic regress because we were too stupid and too slow to get our act together.

Scott Aaronson: Since I hang out with Singularity people so much, part of me reflexively responds: “utopia” could only mean an infinite number of sentient beings living in simulated paradises of their own choosing, racking up an infinite amount of utility.  If such a being wants challenge and adventure, then challenge and adventure is what it gets; if nonstop sex, then nonstop sex; if a proof of P≠NP, then a proof of P≠NP.  (Or the being could choose all three: it’s utopia, after all!)

Over a shorter time horizon, though, maybe the best I can do is talk about what I love and what I hate.  I love when the human race gains new knowledge, in math or history or anything else.  I love when important decisions fall into the hands of people who constantly second-guess themselves and worry that their own ‘tribe’ might be mistaken, who are curious about science and have a sense of the ironic and absurd.  I love when society’s outcasts, like Alan Turing or Michael Burry (who predicted the subprime mortgage crisis), force everyone else to pay attention to them by being inconveniently right.  And whenever I read yet another thinkpiece about the problems with “narrow-minded STEM nerds”—how we’re basically narcissistic children, lacking empathy and social skills, etc. etc.—I think to myself, “then let everyone else be as narrow and narcissistic as most of the STEM nerds I know; I have no further wish for the human race.”

On the other side, I hate the irreversible loss of anything—whether that means the deaths of individuals, the burning of the Library of Alexandria, genocides, the flooding of coastal cities as the earth warms, or the extinction of species.  I hate when the people in power are ones who just go with their gut, or their faith, or their tribe, or their dialectical materialism, and who don’t even feel self-conscious about the lack of error-correcting machinery in their methods for learning about the world.  I hate when kids with a passion for some topic have that passion beaten out of them in school, and then when they succeed anyway in pursuing the passion, they’re called stuck-up, privileged elitists.  I hate the “macro” version of the same schoolyard phenomenon, which recurs throughout cultures and history: the one where some minority is spat on and despised, manages to succeed anyway at something the world values, and is then despised even more because of its success.

So, until the Singularity arrives, I suppose my vision of utopia is simply more of what I love and less of what I hate!

David Deutsch: Of course I’m opposed to utopianism. Progress comes only through piecemeal, tentative improvements. I think the world will never be perfected, even when everything we think of as problematic today has been eliminated. We shall always be at the beginning of infinity. Never satisfied.

Stephen Wolfram: If you mean: what do I personally want to do all day?  Well, I’ve been fortunate that I’ve been able to set up my life to let me spend a large fraction of my time doing what I want to be doing, which usually means creating things and figuring things out.  I like building large, elegant, useful, intellectual and practical structures—which is what I hope I’ve done over a long period of time, for example, with Wolfram Language.

If you’re asking what I see as being the best ultimate outcome for our whole species—well, that’s a much more difficult question, though I’ve certainly thought about it.  Yes, there are things we want now—but how what we want will evolve after we’ve got those things is, I think, almost impossible for us to understand.  Look at what people see as goals today, and think how difficult it would be to explain many of them to someone even a few centuries ago.  Human goals will certainly evolve, and the things people will think are the best possible things to do in the future may well be things we don’t even have words for yet.

Peter Woit: Besides the peace, love and understanding thing, in my utopia everyone else would have as few problems and as much to enjoy about life as I currently do.

Martin Rees: A utopian society would, at the very least, require trust between individuals and their institutions. I worry that we are moving further from this ideal. Two trends are reducing interpersonal trust: firstly, the remoteness and globalization of those we routinely have to deal with; and secondly, the vulnerability of modern life to disruption –- the realization that “hackers” or dissidents can trigger incidents that cascade globally. Such trends necessitate burgeoning security measures. These are already irritants in our everyday life – security guards, elaborate passwords, airport searches and so forth — but they are likely to become ever more vexatious. Innovations like blockchain could offer protocols that render the entire Internet more secure. But their current applications – allowing an economy based on crypto-currencies to function independently of traditional financial institutions –seem damaging rather than benign. It’s depressing to realize how much of the economy is dedicated to activities that would be superfluous if we felt we could trust each other. (It would be a worthwhile exercise if some economist could quantify this.)

And the world is so interconnected that no utopia could exist on the scale of one nation-state.  Harmonious geopolitics would require a global distribution of wealth that’s perceived as fair– with far less inequality between rich and poor nations. And even without being utopian it’s surely a moral imperative (as well as in the self-interest of fortunate nations) to push towards this goal. Sadly, we downplay what’s happening even now in far-away countries and the plight of the “bottom billion.” And we discount too heavily the problems we’ll leave for new generations. Governments need to prioritize projects that are long-term in a political perspective, even if a mere instant in the history of our planet.

Tim Maudlin: In the utopian tradition that goes back to Plato (again!) utopias are not supposed to be real places. In Republic, Socrates says that it does not matter whether the ideal state actually exists: it is a pattern by reference to which one can judge the present situation and how it can be improved. There is a reason why Butler’s Erewhon is about a place called “Erewhon”. But as it happens my present not-yet-in-full-existence utopia is well on its way to full-blown reality. It is called the John Bell Institute for the Foundations of Physics, a non-profit institute formed to promote the study, teaching and investigation of the foundations of physics. So far we have our Faculty and Honorary Fellows and Bell Fellows and regular Fellows, and we have identified where our European campus will be (in Bojanić Bad, Hvar, Croatia) and are seeking an American campus in the Rockies. This is putting my views about utopia to the acid test.

Robin Hanson: My personal utopia would be an intellectual world where we actually lived up to most of the intellectual ideals we espouse. Where work is judged mainly on the long term benefit it gives the world, and arguments are accepted no matter how unpalatable their conclusions, or whose ox is gored. I actually think we know a lot about how to construct such a utopia if we wanted – see my work on futarchy and idea futures. The main problem seems to be that most of us don’t actually want my “utopia.”

Tyler Volk: John, having this opportunity to focus for a spell on your great questions: this is it!

Jim Holt: My utopia is a society that consists in its entirety of Tim and Vishnya Maudlin, David Albert, Jenann Ismael, Shelly Goldstein, Barry Loewer, Carlo Rovelli, Hartry Field, Trevor Teitel, and me, all arguing eternally about gauge theory while beautiful girls and comely boys peel grapes for us.

Nick Herbert: In sociology, I am utterly ignorant. My favorite poet Robinson Jeffers (“Shine, Perishing Republic”) held a dim view of human progress. Perhaps we are now living in the Last Golden Age before the Decline of the West. Whatever the case, Nick offers these words as a guide to rightly living in this odd complexity:

Love this well

ere it perish.

And thank you

for your mystery

which I almost entirely

do not understand.

John Horgan: As I argue in Mind-Body Problems, my free, online book, many of us are already living in pretty good utopias, democracies that give us unprecedented freedom to be who we want to be. But things could be—will be!–a lot better. We will recognize how stupid and wrong war is and end it once and for all. With the money we save from demilitarizing we will end poverty, too, improve education and health care for all, and solve the conundrum of climate change. And we will keep giving ourselves more freedom, more choices. Our children and their children will find new ways to be human, to live good, meaningful lives, ways we can’t even imagine now. This weird, wonderful human adventure will never, ever end. Happy Holidays!

The Inventor of the Genetically Modified Potato Comes Clean


How many years did you spend working on creating GM potatoes? Was this all lab-based work or did you get out to see the farms that were growing the potatoes?

During my 26 years as a genetic engineer, I created hundreds of thousands of different GM potatoes at a direct cost of about $50 million. I started my work at universities in Amsterdam and Berkeley, continued at Monsanto, and then worked for many years at J. R. Simplot Company, which is one of the largest potato processors in the world.

I had my potatoes tested in greenhouses or the field, but I rarely left the laboratory to visit the farms or experimental stations. Indeed, I believed that my theoretical knowledge about potatoes was sufficient to improve potatoes. This was one of my biggest mistakes.

Have the GM potatoes you helped create been approved by the FDA and EPA in the U.S. or indeed elsewhere in the world?

It is amazing that the USDA and FDA approved the GM potatoes by only evaluating our own data. How can the regulatory agencies assume there is no bias? When I was at J.R. Simplot, I truly believed that my GM potatoes were perfect, just like a parent believes his or her children are perfect.

I was biased and all genetic engineers are biased. It is not just an emotional bias. We need the GM crops to be approved. There is a tremendous amount of pressure to succeed, to justify our existence by developing modifications that create hundreds of millions of dollars in value. We test our GM crops to confirm their safety, not to question their safety.

The regulatory petitions for deregulation are full with meaningless data but hardly include any attempts to reveal the unintended effects. For instance, the petitions describe the insertion site of the transgene, but they don’t mention the numerous random mutations that occurred during the tissue culture manipulations. And the petitions provide data on compounds that are safe and don’t matter, such as the regular amino acids and sugars, but hardly give any measurements on the levels of potential toxins or allergens.

The Canadian and Japanese agencies approved our GMO potatoes as well, and approvals are currently considered in China, South Korea, Taiwan, Malaysia, Singapore, Mexico, and the Philippines.

What was your role at Monsanto and J.R. Simplot?

I led a small team of 15 scientists at Monsanto, and I directed the entire biotech R&D effort at Simplot (up to 50 scientists). My initial focus was on disease control but I eventually considered all traits with commercial value. I published hundreds of patents and scientific studies on the various aspects of my work.

Why did you leave firstly Monsanto and then later J.R. Simplot?

I left Monsanto to start an independent biotech program at J.R. Simplot, and I left J.R. Simplot when my ‘pro-biotech’ filter was wearing thin and began to shatter; when I discovered the first mistakes. These first mistakes were minor but made me feel uncomfortable. I realized there had to be bigger mistakes still hidden from my view.

Why have you decided to reveal information about the failings of GM potatoes after spending many years creating them?

I dedicated many years of my life to the creation of GMO potatoes, and I initially believed that my potatoes were perfect but then I began to doubt. It again took me many years to take a step back from my work, reconsider it, and discover the mistakes. Looking back at myself and my colleagues, I believe now that we were all brainwashed; that we all brainwashed ourselves.

We believed that the essence of life was a dead molecule, DNA, and that we could improve life by changing this molecule in the lab. We also assumed that theoretical knowledge was all we needed to succeed, and that a single genetic change would always have one intentional effect only.

We were supposed to understand DNA and to make valuable modifications, but the fact of the matter was that we knew as little about DNA as the average American knows about the Sanskrit version of the Bhagavad Gita. We just knew enough to be dangerous, especially when combined with our bias and narrowmindedness.

We focused on short-term benefits (in the laboratory) without considering the long-term deficits (in the field). It was the same kind of thinking that produced DDT, PCBs, Agent Orange, recombinant bovine growth hormone, and so on. I believe that it is important for people to understand how little genetic engineers know, how biased they are, and how wrong they can be. My story is just an example.

Ask the Expert: Breast Cancer, Diet and Exercise


Cancer Connect

CancerConnect partnered with Dana-Farber to engage with breast cancer expert, Jennifer A. Ligibel, MD, of the Susan F. Smith Center for Women’s Cancers at Dana-Farber. Dr. Ligibel guest-moderated a question-and-answer session on “Breast Cancer, Diet and Exercise.”

Dr. Ligibel has authored several papers on the role of lifestyle factors and breast cancer, including a recent study on the impact of exercise on reducing drug-related joint pain. She is also an assistant professor of medicine at Dana-Farber.

Join us in the Breast Cancer Community on CancerConnect to view the entire Ask the Expert session with Dr. Ligibel.

Question about lifestyle factors, breast cancer and depression: Are there any ‘lifestyle’ type of factors—diet/nutrition, that might help with anxiety, depression (I didn’t seem to have these issues until after my breast cancer diagnosis)?

Dr. Ligibel:There are many studies that show that exercise has a positive impact on anxiety and depression. Studies suggest that fairly modest amounts of exercise can improve mood. We generally recommend that women start slowly and check with their physicians before starting an exercise program, but research suggests that moderate physical activity, such as walking, is safe for most breast cancer survivors and can have many positive health effects.

Although information is more limited in cancer survivors, there is also evidence that weight loss can have a positive effect on depression in women.

Question about health benefits of green tea or tumeric: What do you think of the health benefits of green tea, specifically Matcha green tea? Also, what about tumeric?

Dr. Ligibel:There is a lot of interest in the health benefits of specific supplements, but not much evidence that these products have any benefits for cancer survivors. Green tea has been studied as a potential nausea-preventing intervention, but the results of these studies have been mixed. Some preliminary results from animal studies have suggested health benefits of turmeric, but it is too early to know whether either of these supplements will eventually be shown to be beneficial for cancer survivors.

It is important to note that green tea and turmeric are foods rather than medications, like most supplements. This means that they are not regulated by the FDA. Companies that produce them can make all kinds of health claims, as long as they include the statement that the claims are not supported by the FDA. This can be confusing for patients, as many of these products are marketed as “cancer-fighting”.

Question about Optimal Types of Fat: I’m a 9-year breast cancer survivor. I’ve seen studies which favor a low fat diet to reduce the risk of breast cancer and recurrence. These studies do not specify types of fat. Do they look at or compare trans fats, fat from meat, dairy and processed foods, fats from nuts, seeds, olive oil, coconut oil, etc? I am mostly vegetarian and my diet is actually fairly high in fat since my protein comes from nuts, seeds and some eggs. What is your sense about high fat vs low fat and if the types of fats consumed contribute to higher or lower risk? I’d like to believe that healthy fats are not risk factors! Thank you.

Dr. Ligibel:The study that showed that eating a low fat diet reduced the risk of breast cancer recurrence, called the Women’s Interventional Nutrition Study or “WINS”, was largely conducted in the 1990’s, when there was not as much of a focus on different types of fat. Thus there is unfortunately not a lot of evidence to provide an answer for your question about the impact of different types of fat on breast cancer recurrence rates. However, in the years since the WINS study was conducted, research in other disease such as heart disease, has shown that all fats are not equal in terms of the impact that they have on a person’s risk of developing different diseases. There is also evidence from population studies that suggest that individuals who consume healthy fats seem to be at lower risk of some kinds of cancers, although we can’t determine if there is a cause and effect relationship between the types of fats a person eats and their risk of cancer from this kind of study.

A number of on-going studies are looking at whether there is a “best” diet for breast cancer survivors, but evidence is not conclusive at this point. Some evidence suggests that keeping weight in a good range might be more important than specific dietary ingredients. The National Heart, Lung and Blood Institute, a group that prepares many of the recommendations about weight and diet for the US population, currently supports the use of a number of diets to maintain a healthy weight.

Thus there is no simple answer to your question, but if your diet is successful in keeping your weight in a good range, it is likely a reasonable plan for you to continuing following.

Question about Exercise and Health Benefits: I have a very physically demanding job where I move at a great clip outdoors for at least 3-4 hours each day. When I am done work I have no energy for formal exercise, especially since BC treatment and Tamoxifen, just stretching or a little Yoga. Is this enough?

Dr. Ligibel:Studies have shown that physical activity, no matter how it is achieved is linked to better outcomes in breast cancer. Sometimes it is hard to know how much activity a person is doing as part of a work day, so one way to make sure that you are doing enough exercise is to wear a pedometer to track the distance you walk each day as part of your job and during your leisure time. You should aim for 10,000 steps per day. If you are accomplishing this much walking during your average work day, you are likely achieving enough physical activity to provide health benefits.

Question about Weight Loss: I am taking Anastrozole. It is very difficult to lose weight. Do you have any suggestions as to offsetting the effects of this medication on weight loss? What should the majority of the diet include and what should be omitted in order to lose weight?

Dr. Ligibel:There are many reasons why woman with breast cancer gain weight or have difficulty in losing it after breast cancer diagnosis. Some women go through menopause as a result of chemotherapy or other cancer treatments. The average women who undergoes a “normal” menopausal (not due to cancer treatment) will gain 5-10 pounds in the years after her menstrual cycles stop. This weight gain can be even greater when it occurs suddenly as a result of breast cancer treatment. Many women also feel fatigued as a result of their breast cancer therapy and become less physical active. Studies have shown that weight gain is not increased in women taking tamoxifen or anastrozole, but it is harder to study the effects of these drugs on a woman’s ability to lose weight.

Regardless of the reasons for weight gain, weight loss requires calorie reduction. This can be accomplished in many ways. A diet that is low in fat and high in fruits and vegetables has been a standard for weight loss for many years, but low carbohydrate, vegetarian, low glycemic index and Mediterranean diets can also be used to lose weight. Many people find keeping a journal of what you eat and drink as a first step to understanding your eating patterns. You might be surprised by “hidden” calories you are consuming. Some people also find a structured meal plan to be helpful when starting a weight loss program. Commercial programs can also be useful to teach you how to recognize where your calories re coming from and create new eating patterns.

Question about Diet/Exercise Resources: Do you have any recommendations for books or resources that would be a good guide to helping with navigating the best things to do for nutrition/exercise after breast cancer?

Dr. Ligibel:The American Cancer Society has developed a set of diet and nutrition guidelines for cancer survivors that is available on its web site.

The American Society of Clinical Oncology has also made Obesity and Cancer one of its primary initiatives this year and will be releasing a set of materials about weight, nutrition, and diet for cancer survivors in the next few weeks. This materials will be available in print and online through the Cancer.net website.

Question about Neuropathy: Can diet or exercise help neuropathy from chemo?

Dr. Ligibel:There is not a lot of evidence that diet or exercise can help neuropathy from chemotherapy. There are studies looking at glutamine, a supplement, but this product seems to work best while an individual is receiving chemotherapy treatments. On-going studies are looking at acupuncture as a potential treatment for chemotherapy-induced neuropathy.

Question about Prevention: What should we tell our daughters, sisters, mothers, wives, girlfriends about diet/exercise to help them prevent breast cancer?

Dr. Ligibel:There is a lot of evidence that a “healthy” lifestyle—keeping your weight in a healthy range, exercising regularly, and consuming a diet that is higher in fruits and vegetables and lower in fat—could reduce the risk of developing breast and other cancers. This doesn’t mean that these behaviors are 100% effective in preventing breast cancer or that people who don’t do any of these things will necessarily develop breast cancer, but the evidence does suggest that maintaining a healthy lifestyle should be part of a cancer prevention strategy.

General nutrition and physical activity recommendations from the American Cancer Society for Cancer Prevention include the following:

1. Stay Active: perform at least 150 minutes of moderate-intensity aerobic exercise each week, such as walking at a brisk pace

2. Consume a healthy diet that is low in fat and high in fruits, vegetables and fiber

3. Maintain your weight in a healthy range and attempt weight loss if you are overweight or obese

4. Limit alcohol to no more than 1 drink per day for women and 2 drinks per day for men

Question about Immune System: My questions are three-fold: First- does boosting the immune system help prevent breast cancer? Second, Is there a diet that boosts the immune system (I am a vegetarian)? And, lastIy, I just read something about a study showing that a vegetarian diet is linked to poor health—what does this mean to me as a breast cancer survivor?

Dr. Ligibel:There is a lot that we do not know about the biology that links nutrition and exercise to breast cancer. Some scientists have hypothesized that the immune system may play a role in this connection, but there is little conclusive evidence. Similarly there is not much known about how specific foods or supplements affect the immune system, so I would not recommend a particular diet to enhance the immune system.

Finally, vegetarian diets can be very healthy, as long as they contain a good balance of essential nutrients. It can be hard to consume enough protein, for example, for individuals who maintain a vegetarian diet. As long as you ensure that you consume a balanced diet, there is no reason why a vegetarian diet would be unhealthy. If you have specific concerns regarding your diet, I would recommend meeting with an oncology nutrition specialist.

Question about Diet/Exercise to help with fatigue: I have metastatic breast cancer—been on multiple treatments for what seems like forever. I am grateful to be alive but am beginning to feel what I assume are the cumulative effects of all of my treatments. Are there any recommendations for food or exercise that might help with my fatigue?

Dr. Ligibel:There is unfortunately very little information about the role of diet and exercise in patients with advanced breast cancer. However, exercise has been shown to be an effective way to reduce fatigue in many studies performed in women with early-stage cancer undergoing chemotherapy. There have been a few small studies of moderate-intensity exercise in women with advanced cancer that suggest that exercise is safe and may have benefits. I would recommend asking your doctor about starting an exercise program. As long as he or she is supportive of this, I would recommend slowing starting to exercise. It is important to set reasonable goals, and begin slowly. If you have not been exercising at all, even just walking around the block once per day can be a good start. Build up the time that you spend exercise each week, and you will likely begin to see some benefits in terms of your energy level.

Question about Weight Loss: I was diagnosed with Stage 4 Inflammatory Breast Cancer last July at the age of 31. I am currently on maintenance treatment and need to lose about 40-50 pounds. I lost a lot of my strength during treatment and I am a pretty picker eater who hates to cook. The thought of having to lose that much weight is so overwhelming even though I know it will help to decrease recurrence. Can you tell me what 2 or 3 things (whether nutrition or exercise related or both) that I can start with?

Dr. Ligibel:It can be daunting to know where to figure out where to start when you would like to lose a lot of weight. We find that people are most successful when they start with an attainable goal. Studies have shown that smaller amount of weight loss, 5-10% of your starting body weight, can have many benefits, even if people can’t lose 50 pounds.

I would recommend that you start with keeping track of what you eat for a week. Look for “hidden” calories like soft drinks, alcoholic beverages or juices, which are high in calories and not filling. Processed foods and sweets are also very high in calories with less nutritional value. Try to limit the amount of these you consume.

Start slowly with exercise if you have not been active. Make a plan to start with walking at a moderate pace for 10-15 minutes three times per week and gradually increase to every day, and then for longer periods of time.

Joining a group program (like Weight Watchers) can also be helpful for some people, or working with a weight loss “buddy”, a person with whom you can explore low calorie recipes and exercise, works for some people.

Question about Maca: I am taking Femara for ER & PR + stage III breast cancer. Is it safe to take Maca to help manage side effects of the AI?

Dr. Ligibel:There is unfortunately no safety data for this supplement for women with breast cancer.

Question about Soy: My question concerns tamoxifen, nutrition and products that contain soy. I was diagnosed 1/19/12 with invasive ductal carcinoma PR+ ER+ HER2+ and received bilateral lumpectomies, No lymph node involvement either side, 16 taxol/herception weekly infusions, 33 radiation rounds, 4 A/C, and the year’s course of Herceptin. I have been taking tamoxifen for the last year and a half and have read conflicting information about soy products. Although my hot flashes have subsided a bit, they do keep wake me up at night. I realized that many protein rich yogurts and nutrition bars have traces of soy in them. I considered soy as a supplement initially but decided against it, since the research appeared to be “”out”” on the final word (soy mimics estrogen but does it tend to promote my type of estrogen-driven cancer?). What are your thoughts on how much soy is “”good”” or harmful in contributing to recurrence? I appreciate your opinion. ”

Dr. Ligibel:There is a lot that we do not know about the relationship between soy and estrogen-driven breast cancers. Early studies showed that high doses of soy led to breast cancer formation in lab experiments, but it is not clear whether this amount of soy was remotely similar to what a woman could consume through diet. A number of recent reports looking at diet patterns in women in Asia and the US suggested that the risk of breast cancer recurrence was not increased by soy intake. Although there are some difficulties in using this information to completely conclude that soy intake is “safe” for breast cancer survivors, most experts at this point feel fairly confident that some soy intake in the diet is unlikely to be dangerous for breast cancer survivors. This means that it is likely not necessary to be reading food labels to avoid products containing soy, but I would personally stop short of endorsing soy as a supplement for a breast cancer survivor.

Question about Foods to Avoid: Are there any specific foods we should stay away from specifically if you are positive to estrogen?

Dr. Ligibel:There is a lot of debate regarding the use of soy products in women with an estrogen-positive breast cancer (please refer to the prior question regarding soy). Other foods also contain phytoestrogens, which are plant-based substances that are similar in structure to hormonal estrogen but come from plant sources. There is not a lot of definitive evidence about the risks or benefits of any of these products in women with breast cancer, but as a general rule, the moderate amounts of most of these substances in foods are considered safe.

Therefore, I would not say that there is good evidence that any food needs to be avoided for women with breast cancer, but soy products, flax seed, and alcoholic beverages (which also increase estrogen in some situations) should be taken in moderation.

Would Human Extinction Be a Tragedy?


Our species possesses inherent value, but we are devastating the earth and causing unimaginable animal suffering.

An overgrown lot along Highway 13 near the town of Haleyville, Ala.CreditWilliam Widmer for The New York Times.
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An overgrown lot along Highway 13 near the town of Haleyville, Ala.CreditCreditWilliam Widmer for The New York Times

There are stirrings of discussion these days in philosophical circles about the prospect of human extinction. This should not be surprising, given the increasingly threatening predations of climate change. In reflecting on this question, I want to suggest an answer to a single question, one that hardly covers the whole philosophical territory but is an important aspect of it. Would human extinction be a tragedy?

To get a bead on this question, let me distinguish it from a couple of other related questions. I’m not asking whether the experience of humans coming to an end would be a bad thing. (In these pages, Samuel Scheffler has given us an important reason to think that it would be.) I am also not asking whether human beings as a species deserve to die out. That is an important question, but would involve different considerations. Those questions, and others like them, need to be addressed if we are to come to a full moral assessment of the prospect of our demise. Yet what I am asking here is simply whether it would be a tragedy if the planet no longer contained human beings. And the answer I am going to give might seem puzzling at first. I want to suggest, at least tentatively, both that it would be a tragedy and that it might just be a good thing.

To make that claim less puzzling, let me say a word about tragedy. In theater, the tragic character is often someone who commits a wrong, usually a significant one, but with whom we feel sympathy in their descent. Here Sophocles’s Oedipus, Shakespeare’s Lear, and Arthur Miller’s Willy Loman might stand as examples. In this case, the tragic character is humanity. It is humanity that is committing a wrong, a wrong whose elimination would likely require the elimination of the species, but with whom we might be sympathetic nonetheless for reasons I discuss in a moment.

To make that case, let me start with a claim that I think will be at once depressing and, upon reflection, uncontroversial. Human beings are destroying large parts of the inhabitable earth and causing unimaginable suffering to many of the animals that inhabit it. This is happening through at least three means. First, human contribution to climate change is devastating ecosystems, as the recent article on Yellowstone Park in The Times exemplifies. Second, increasing human population is encroaching on ecosystems that would otherwise be intact. Third, factory farming fosters the creation of millions upon millions of animals for whom it offers nothing but suffering and misery before slaughtering them in often barbaric ways. There is no reason to think that those practices are going to diminish any time soon. Quite the opposite.

Humanity, then, is the source of devastation of the lives of conscious animals on a scale that is difficult to comprehend.

To be sure, nature itself is hardly a Valhalla of peace and harmony. Animals kill other animals regularly, often in ways that we (although not they) would consider cruel. But there is no other creature in nature whose predatory behavior is remotely as deep or as widespread as the behavior we display toward what the philosopher Christine Korsgaard aptly calls “our fellow creatures” in a sensitive book of the same name.

If this were all to the story there would be no tragedy. The elimination of the human species would be a good thing, full stop. But there is more to the story. Human beings bring things to the planet that other animals cannot. For example, we bring an advanced level of reason that can experience wonder at the world in a way that is foreign to most if not all other animals. We create art of various kinds: literature, music and painting among them. We engage in sciences that seek to understand the universe and our place in it. Were our species to go extinct, all of that would be lost.

Now there might be those on the more jaded side who would argue that if we went extinct there would be no loss, because there would be no one for whom it would be a loss not to have access to those things. I think this objection misunderstands our relation to these practices. We appreciate and often participate in such practices because we believe they are good to be involved in, because we find them to be worthwhile. It is the goodness of the practices and the experiences that draw us. Therefore, it would be a loss to the world if those practices and experiences ceased to exist.

One could press the objection here by saying that it would only be a loss from a human viewpoint, and that that viewpoint would no longer exist if we went extinct. This is true. But this entire set of reflections is taking place from a human viewpoint. We cannot ask the questions we are asking here without situating them within the human practice of philosophy. Even to ask the question of whether it would be a tragedy if humans were to disappear from the face of the planet requires a normative framework that is restricted to human beings.

Let’s turn, then, and take the question from the other side, the side of those who think that human extinction would be both a tragedy and overall a bad thing. Doesn’t the existence of those practices outweigh the harm we bring to the environment and the animals within it? Don’t they justify the continued existence of our species, even granting the suffering we bring to so many nonhuman lives?

To address that question, let us ask another one. How many human lives would it be worth sacrificing to preserve the existence of Shakespeare’s works? If we were required to engage in human sacrifice in order to save his works from eradication, how many humans would be too many? For my own part, I think the answer is one. One human life would be too many (or, to prevent quibbling, one innocent human life), at least to my mind. Whatever the number, though, it is going to be quite low.

Or suppose a terrorist planted a bomb in the Louvre and the first responders had to choose between saving several people in the museum and saving the art. How many of us would seriously consider saving the art?

So, then, how much suffering and death of nonhuman life would we be willing to countenance to save Shakespeare, our sciences and so forth? Unless we believe there is such a profound moral gap between the status of human and nonhuman animals, whatever reasonable answer we come up with will be well surpassed by the harm and suffering we inflict upon animals. There is just too much torment wreaked upon too many animals and too certain a prospect that this is going to continue and probably increase; it would overwhelm anything we might place on the other side of the ledger. Moreover, those among us who believe that there is such a gap should perhaps become more familiar with the richness of lives of many of our conscious fellow creatures. Our own science is revealing that richness to us, ironically giving us a reason to eliminate it along with our own continued existence.

One might ask here whether, given this view, it would also be a good thing for those of us who are currently here to end our lives in order to prevent further animal suffering. Although I do not have a final answer to this question, we should recognize that the case of future humans is very different from the case of currently existing humans. To demand of currently existing humans that they should end their lives would introduce significant suffering among those who have much to lose by dying. In contrast, preventing future humans from existing does not introduce such suffering, since those human beings will not exist and therefore not have lives to sacrifice. The two situations, then, are not analogous.

It may well be, then, that the extinction of humanity would make the world better off and yet would be a tragedy. I don’t want to say this for sure, since the issue is quite complex. But it certainly seems a live possibility, and that by itself disturbs me.

There is one more tragic aspect to all of this. In many dramatic tragedies, the suffering of the protagonist is brought about through his or her own actions. It is Oedipus’s killing of his father that starts the train of events that leads to his tragic realization; and it is Lear’s highhandedness toward his daughter Cordelia that leads to his demise. It may also turn out that it is through our own actions that we human beings bring about our extinction, or at least something near it, contributing through our practices to our own tragic end.

Cardiologists and Airline Pilots: Mark Nicholls Speaks to Interventional Cardiologist Dr Bill Lombardi About What the Profession Can Learn From the Airline Industry


Every time a commercial pilot encounters a complication, the airline involved conducts an immediate root-cause analysis and shares the findings throughout the industry with the focus on the problem and the appropriate response, rather than blame. Pilots, argues interventional cardiologist Dr Bill Lombardi, welcome the process as it keeps their skills sharp. However, no such feedback-improvement loop exists for interventional cardiologists, he notes, despite performing their role with similar life-or-death consequences.

Bill Lombardi believes a culture change is required to prise cardiologists ‘out of a too-cautious posture’ and enable them to have the confidence and skill sets to perform more challenging procedures for the benefit of patients without the fear of litigation or criminal investigation. At present, he suggests, fear of potential complications often results in cardiologists declining to perform procedures in complex cases or readily share data when complications occur. With interventional cardiologists, the norm is to quietly review and learn without sharing the information, and perhaps deciding not to take on such riskier cases in the future, Lombardi says.

The son of an airline pilot, he suggests, this is ultimately counter-productive and that interventional cardiologists should follow the example of his father’s profession and adopt the commercial airlines’ ‘feedback improvement loop’.

Lombardi, who directs Complex Coronary Artery Disease Therapies at UW Medicine—the health system of the University of Washington—outlined his views at a ‘learning from complications’ symposium in Seattle in August, one focus of which was how cardiologists could improve by sharing information about mistakes or unforeseen complications to learn from them and avoid repeating them.

Lombardi said: ‘Instead of hiding complications and being fearful of describing complications, or being somewhat protectionist and having a heavy emphasis on avoidance rather than learning from them, what we want to try and do is discuss the challenges of our profession in doing more complex procedures. How do we develop a better way to share global experience in a way that others can learn from other’s mistakes rather than having to repeat them or learn them on their own?’

In aviation, accident scenarios can arise out of a minor technical malfunction, but escalate because of hurried subsequent decisions. This is mitigated through communication and regular training. He advocates the development of a structured work process for cardiologists with checklists and educational updates, so that when a complication occurs, it is a learning opportunity for all practitioners.

For instance, the famous landing of US Airways flight on the Hudson River—as portrayed by Tom Hanks in the film ‘Sully’—was possible because the commercial pilot had rehearsed the scenario of multiple engine failures as part of ongoing training and was able to calmly respond. And after a catastrophic engine failure caused the 1989 crash of a DC-10—the aircraft type his father flew—all DC-10 pilots were mandated to fly the crash and the appropriate response on a simulator. ‘The impetus of the symposium and was to bring some of that sensibility to our profession’, said Lombardi, a specialist in cardiac catheterisation and interventional cardiology.

At present, he says many interventional cardiologists differ significantly from commercial pilots when they encounter a complication. ‘There is a lot of risk-avoidance’, he suggests, ‘of avoiding therapies that would have benefit to patients but are avoided because of lack of competency and lack of understanding of how to manage the consequences of a poor decision’. It would be like saying an airline pilot is only going to fly when the weather is beautiful. ‘That is because we don’t fundamentally train the minimum competences of interventional cardiologists to the level of a pilot. The minimum competency to do interventional cardiology is more analogous to flying a Cessna, a little single-engine plane, in beautiful weather, rather than the competency required of a commercial or military pilot’.

Lombardi thinks the hierarchical structure of cardiology contributes to this culture with a top-down, rather than horizontal, education process. He also expressed concern about communication practices, in which the senior physician dictates what happens during procedures and other points of view are not encouraged. ‘In contrast, cockpit communication is very horizontal between pilot, flight attendants, and air traffic control. That certainly is not nurtured and developed within our profession’.

And when a complication does occur, few mechanisms exist to share and broadly learn from it. There is more of a culture of blame, he said. The lack of such a feedback-improvement loop for interventional cardiologists may stem from fear of malpractice litigation, which encourages practitioners to shy away from an open dialogue.

Lombardi advocates minimum competencies that practitioners must acquire and demonstrate in a more structured way. That, he says, would require hospitals and healthcare systems to send interventionalists to annual courses of case simulation and didactics, updates on potential complications, treatment and new data. People would be forced to maintain a minimum competency—exactly the same as the airline profession. Once you have built that kind of culture, you can look at a complication with a central resource data set. It can be reviewed by a panel and yield learning objectives that go back to the institution and the operator. Ultimately, it can be among the annual educational updates for the profession.

‘In an ideal world, that is what we would get to’, he said ‘It would not be litigation and criminal justice to help doctors learn but the value of education and competency’.

Lombardi suggests this reluctance to learn from mishaps is a global issue across healthcare more generally, not specifically interventional cardiology. ‘I speak of interventional cardiology because it is what I know, but I think it is a wider problem. Patients might assume that every doctor with similar training has the same skills, but because we lack measurable competencies, that is not actually true’.

He is convinced that if practitioners had better minimum competencies and a better understanding of potential consequences of decisions, patients would receive better care. ‘If you work in an objective way to improve management of complications and reduce not just the number of complications but the consequences of those complications, that actually saves healthcare systems and hospitals tremendous amounts of money as well as helping patients. In the long term, it would give patients more trust that when they are getting treated, the person treating them actually has the skill sets to take good care of them’.

Such a transformation could take a decade to bring about tangible improvements.

‘If we can start to build a constructive discussion and construct, one that is not going to offend but one that is going to actually highlight the benefits, then we have an opportunity to start changing the culture, which should then help improve patient care’.

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