Let’s Take A Closer Look

One evening in 1978, when I was in medical school, I described to a few dinner companions a fantasy/sci-fi machine for diagnosing illnesses.  CT scanners (which provide multiple computer-generated cross-sectional views, or tomographs, of the body using x-rays) had only recently been invented, and MRI (using NMR technology taught to us in physical chemistry classes at the time) was still a few years away.

My dream machine, I explained to my dinner mates– whose eyes I could see were beginning to glaze over– would compile all the tissue cross-sections to generate a 3-D picture, a hologram.  At that time, CT’s limited resolution showed us the organs and tissues, but what if we could greatly increase the resolution with a different type of energy beam, something other than x-rays?  Radar?  Microwaves?  Cosmic rays?  Who knew?  We would see not only tissues but cells, then drill down to the level of cell nuclei, mitochondria, chromosomes, even individual genes.  The resolution of the imaging technique was the rate-limiting step.

With my dream machine, abnormal cells would stand out right away; combine that information with indicators of tissue metabolism (PET scanners would come along later) and even images of gene sequences, and before you knew it, surgical biopsies of live tissue– for example, to diagnose cancer– would no longer be needed.  “You could examine the hologram from all different angles, then perform a virtual biopsy!” I exclaimed (stimulated by the excellent wine we had with dinner).  The computer, having obtained all necessary data from the high-resolution scan, could “biopsy” pieces of the 3-D image, then project them on a screen for the pathologist:  this could be repeated over and over, without any pain to the patient.

Well, the dream machine is one step closer.  This week– only 36 years later– a newsletter from the dean of Yale Medical School announced the arrival of a high-resolution cryoelectron microscope with tomographic capabilities, enabling researchers to view specimens in 3-D from multiple angles (unfortunately you still have obtain a specimen, as nobody has figured out how to put a whole patient into the machine).  It can tell us the atomic structures of membrane proteins– now that is small!  By the way, the three scientists most responsible for developing cryo-EM received the Nobel Prize in Chemistry this month.

(Not making any claims to the Nobel Prize– just saying).  Here’s an excerpt from my science fiction novel, Fourth World:

Lora stepped out of the Pan-Bio Analyzer, commonly known as the Probot, and reached for her paper robe.  Her skin was flushed and tingling- it felt like a Sonicspray, she thought, only without the blowing sensation.  The Probot scan, which produced a detailed analysis of anatomy and organ function- it would have detected a gastric ulcer, sinus infection or brain tumor, for example- was the final part of the physical evaluation required of all students, and she had passed without a hitch.  So had Benn and Sool, who were already on their way to the first formal lecture for the incoming class of interns, scheduled to begin in Cushing Hall in just a few minutes.  After a week of organizational meetings and introductory talks, it was a much-anticipated moment.

Lora nodded to the technician seated at a control panel, hurriedly crossed the cold Probot Chamber to the adjacent dressing room, and exchanged the robe for her standard-issue orange bodysuit.  Almost everyone attending YaleConn Med- not only the lowly interns- wore those bodysuits to class, so Lora shrugged off their resemblance to the prison uniforms worn by PsySoc reformees back at Tharsis One.  In a way, Lora was disappointed that the computer hadn’t found anything wrong with her:  no explanation for the distracting noise, that persistent insect buzz that had kept her up for part of the night.  It was faint, but intermittently took on a pronounced throbbing pattern- quite annoying.  Neither Benn nor Sool seemed to hear that noise, whatever it was:  A blood clot?  Eustachian tube dysfunction?  Seizure activity?  The Probot said no, no and no.  Meaning that there wouldn’t be an easy remedy.




Mars or Bust II

It’s really happening.  Among Earthbound, upward-gazing humans, there has always been a deep-seated fascination with outer space; witness the huge popular reaction to the recent solar eclipse.  But efforts by SpaceX, Boeing, Blue Origin and other commercial companies to fly folks into low Earth orbit in conjunction with NASA signal an acceleration of that interest, or what has been called a “new space race.”  When rocket factories, cargo missions, passenger flights and space exploration open up “a whole new world of business,” you know that momentum will build.  According to a NASA director, a manned mission to Mars is “the pinnacle of Mt. Everest” at this point– but once Everest has been scaled, what will keep the momentum going?

In my science fiction novel Fourth World, NASA’s Tharsis Colony on Mars is left stranded when a great war results in the formation of one world government (the PWE) and the elimination of NASA.  Here’s an excerpt:

“At other times, Mr. Walker suggested that the colony’s downfall actually preceded the PWE, that the slow death- he termed it the “apoptosis”- of Tharsis Colony was encoded in its DNA at the very moment it was conceived.  To explain this apoptosis, Mr. Walker would use his guiding principle:  follow the water.  The second manned mission to Mars, launched in 2049 (thus nicknamed “The New Forty-Niners”) discovered significant quantities of liquid underground water, which had only to be mined in order to allow large-scale colonization. Of course, water was necessary for supporting life, but beyond that, water was found in perchlorates, hydrated salts which could be converted to solid rocket fuel (this was before the harnessing of nuclear fusion, Mr. Walker reminded them).  The seminal discovery of water, he said, sweeping both arms dramatically to his left, then to his right, essentially divided the history of humanity on Mars into the pre- and post-Forty-Niner eras.”

Regarding the former, Mr. Walker reviews for his second-grade class the decades-long history of Mars exploration:

“… Many other missions contributing to the ultimate colonization of Mars, such as Mariner, Pathfinder, the Mars Reconnaissance Orbiter, Opportunity and Spirit, were never forgotten by history.

Also never forgotten:  the fact that the United States agency NASA had been responsible for all of these missions.  Sure, Mr. Walker allowed, successful probes were launched by Russia, Europe, China, India, Brazil, New Zealand, and even private enterprises.  But only the United States had the means to access the water- to monopolize this most vital of natural resources- and establish a full-fledged colony.  Tharsis was a triumph for the United States, but to the rest of the world, it was only the latest example of American empire-building and colonialism.”

But merely finding the means to colonize Mars doesn’t explain the need to colonize, does it?  There have to be assets to exploit once you get there (and in Fourth World, it turns out, there are valuable resources to discover).  Absent such assets, would escaping Earth justify the trouble and cost of such a long journey?  Despite Hurricane Harvey’s devastating effect on Texas and the startling rise in the number of 500-year floods in just the past decade, climate-change deniers in Congress and the White House still determine US policy.  It seems we will continue to prop up the coal industry until all the coal mines are under floodwaters.  In the original Mars or Bust (which appeared on this blog January 7th, while I was still in post-election shock), I coined a name for the manned SpaceX mission to Mars:  Elon’s Ark.  Let’s hope commercial space flight literally takes off:  when climate change can no longer be reversed, we’re going to need a lot more than one Ark!


To Join This Couple

If only it were possible to love without injury- fidelity isn’t enough:  I had been faithful… and yet I had injured her.  The hurt is in the act of possession:  we are too small in mind and body to possess another person without pride or to be possessed without humiliation.”

The Quiet American, by Graham Greene


Proximity to several weddings and anniversaries has got me thinking not only about hope and wonderful relationships, but also- this may seem a bit neurotic- about the impossibility of attaining the ideal:  complete mutual understanding.  Ideal goals, almost by definition, are impossible to reach- and yet (one hopes) we strive on, grinding the rough corners, losing the old baggage, constantly adjusting our attitudes toward one another and admonishing ourselves to be better people.  In other words, if we are “too small in mind and body,” we need to keep growing!  If only there were an easier way; if only we had chimeric genes or the drug-induced ability to escape our limited dimensions and merge together, like Benn and Lora in Fourth World, both projecting their auras in an out-of-body experience:

“HUH!” was all Benn could manage as their two auras met.  It was not so much a physical joining of bodies- not the sensation he had hoped for, alas- but more like a merging of two liquids.  Lora feels like oil, the odd thought came to him: he pictured a large drop of oil falling into a pool of water.  As it splashed, the strong natural repulsion between auras took immediate effect:  the drop embodying Lora displaced a smaller drop- a portion of Benn’s aura- which rose straight upward.  Then the Benn-drop fell back in and splashed up an even smaller droplet- Lora again- which in turn fell, and so on, until inevitably the last micro-sphere of Lora was captured by Benn’s surface tension and could no longer escape.  As separate liquids, the two of them had different viscosities:  Benn flowed easily, whereas Lora’s character was thicker, more unctuous.  Their collision caused long, finger-like projections of Lora to penetrate into Benn’s aura, causing it to blush red before snapping back to attention.

He recognized her myriad layers, those melodic strains, the steady internal rhythm he had so admired.  With their thoughts intermingled, mutual understanding arrived instantaneously, and no longer required the cumbersome verbal exchange of ideas expressed ploddingly one at a time, over periods measurable on a stopwatch.”

If only we could do that!  But in the sequel, Fourth World Nation, Benn wrestles with the ups and downs of sharing auras:

“Benn thought long and hard before giving his answer.  Even though she had quickly apologized and even made a joke about it, Lora had meant what she said about the survival of their relationship.  Admittedly, he often worried about misconstruing her intentions, being insensitive, and appearing apathetic when he really did care; why would she not have her own set of worries about appearing moody, contentious, or needy when she was anything but?  Only when their auras fused together was there instantaneous and true knowledge of one another.  Who wouldn’t want a relationship completely free of misunderstandings, mistrust, manipulation, projection, guilt, dishonesty or domination?  No more mumbling, lapses of attention, slips of the tongue or difficulty hearing, either!  What could be better?”

Unlike Benn and Lora, the rest of us remain in separate, finite minds and bodies.  It’s as though we are talking through a wall, in different languages, our voices muffled and disguised.  Of course we’ll never achieve complete understanding that way, so we need to keep growing, grinding, adjusting.  But come to think of it, this continual striving on our parts reflects an untiring commitment to our relationships, doesn’t it?  We may not hear each other perfectly well, but that untiring commitment, I think, is at least one ideal we can attain.



Just Act Natural, If You Can

In my early practice, I used to have a patient- a handsome, urbane Chinese man in his thirties- who had appeared in a number of car commercials.  He seemed successful, and yet at every doctor’s visit, even before mentioning his health, he would complain about the lack of acting roles for Asian actors.  It was more important to him, he said, than his blood pressure!  This turned out to be a widespread frustration which has resulted in activism, educational endeavors, signed petitions and quasi-political gatherings across the country.  George Takei (Mr. Sulu) has been particularly outspoken on the topic.

In the 1930s, the Chinese stereotype depicted in movies ranged from the super-smart, respectful and submissive Charlie Chan to the super-smart, evil and insidious Dr. Fu Manchu.  These were two Chinese extremes, and yet, as Asian activists love to point out, Charlie Chan was played by a Swedish actor, Warner Oland, and Fu Manchu by another Caucasian actor (I forget his name) in yellowface.

Another stereotype is the martial artist, and here at least, we see Bruce Lee, Jet Li, Jackie Chan and other Chinese actors in kung fu movies.  And who can forget Michelle Yeoh and Zhang Ziyi in Crouching Tiger, Hidden Dragon?  All fighting with hands, feet, sticks and swords.  But where is the Asian Meryl Streep, Harrison Ford, Tommy Lee Jones, or even Woody Allen?  Maybe there won’t ever be one.  Does the necessary depth of character and experience lie beyond what Hollywood expects from such actors, based on Asian stereotypes?  Now Daniel Dae Kim and Grace Park are departing from the cast of Hawaii Five-O, allegedly because of unequal treatment and pay.  The show is based in an Asian-dominant environment, and yet the Asian actors are considered secondary.

When I wrote the sci-fi novel Fourth World, I chose a Chinese youth- Benn Marr- as the protagonist, the hero/anti-hero.  True, I was motivated by concern over the exploitation of post-colonial Third World countries; the European nations’ intolerance of their colonial subjects, now transplanted minorities in the homeland; and- part of the autobiographical element in Fourth World- the difficulty finding acceptance when coming in from the outside.  I wanted Benn to wrestle with not-belonging, and to crystallize these types of issues.  But it’s also true that, in thinking about my long-ago former patient, I wanted to create a leading role for a Chinese actor (John Cho?), in case Fourth World ever becomes a movie!  I know, dream on…

China On The Rise

Last night, Harvard Prof. Graham Allison gave a talk, moderated by former Rep. Ellen Tauscher, at the Commonwealth Club in SF.  The topic was his new book, Destined for War:  Can America and China Escape Thucydides’s Trap?  Five centuries BC, Thucydides noted that the threat from a rising power, Athens, as perceived by Sparta- the ruling power in ancient Greece- led to the Peloponnesian War.  He drew a parallel with US/China relations- acknowledging some of the shortcomings of such a comparison, which have been amply pointed out in various reviews of the book.  China, he said, has caught up with the US in every major parameter, and surpassed it in some.  For example, when Reagan was president, China’s GDP was 10% that of the US, and now it is 110%.  In many aspects of technology, China is taking the lead:  social media, AI, robotics, clean energy, electric vehicles etc.  The US still leads by far in the military arena, but China may not care as much as we suppose (Allison reminded us that, when US and South Korean troops once pushed back a North Korean invasion almost to the Chinese border, China used conventional weapons to fight the sole nuclear power on Earth, all the way down to the 38th parallel).  Economic “warfare” is just as important these days, and as the US withdraws from the world stage (see TPP), you have to wonder:  which country now represents Sparta, and which Athens?  Sharing common interests- such as avoiding nuclear holocaust and preventing global warming- lowers the risk of war, but then having a belligerent and unpredictable president who denigrates NATO and pulls out of the Paris Accord weakens those commonalities.  It seems to me that under our Chaos President, fear of “Mutual Assured Destruction” (MAD) and climate change may not be enough to prevent war.  Also, the strong chauvinism and national fervor among Chinese- not mentioned in the talk- may tilt the balance towards war when a crisis erupts, for example on the Korean Peninsula or South China Sea.  As I pointed out in an earlier blog (A Day Without Women), the world is a lot more complicated now, but Thucydides may be right after all.

Here’s an excerpt from my sci-fi novel Fourth World, in which Chou Xia-Yu, leader of the world government in 2196, ponders the fate of expatriate anomaly Benn Marr:  will he have to be destroyed?

Chou silently nodded his satisfaction at the inherent justice of it all:  descendants of the American colonists on Mars had paid a steep price to atone for the imperialist policies of their ancestors.  And now, he speculated, this Benn Marr represented another level of reward for years of experimentation.  The ability to read and to project thoughts was similar to what Chinese monks (particularly in the Tibetan District) had been practicing for a thousand years.  The difference was that Eunigen had given Benn his abilities by modifying his genes, so that they could be passed on to future generations in large numbers:  the hypothetical implications for the PWE were staggering!  Unfortunately, Benn Marr, although of Chinese descent, had lost touch with his ethnic roots on Mars, and had no understanding of his rich cultural heritage.  As with all traditional Chinese, Leader Chou harbored the conviction that the Chinese civilization had greater value- it was simply superior- and should be promoted above all others; Benn was unlikely to feel such loyalty.

Looking Good, Mate!

Is it more important to look good, or be good?  Here’s an excerpt from Fourth World, in which Benn Marr unravels a knotted debate over the use of recombinant genes purely for cosmetic purposes:

When the crowd noise had settled, Dr. Neelin shook his head and said, “I confess, I would never have thought of applying the principle of Natural Selection.”  He sighed at the sea of vacant faces and added, “For those unfamiliar, it’s the passing down of genes which increase survivability, for the good of the species.  For a thousand years, outward appearance has replaced survivability as the driving criterion in choosing a mate, has it not?  What did you so aptly call it, Benn- “Unnatural De-selection”?  Thanks to cosmetic procedures, Mr. Marr is telling us, genes that weaken the species are just as likely to be passed along as genes that promote survival of the fittest.  It’s hardly better for the human species than, say, choosing mates by the attractiveness of their clothing!”

Richard Prum, an ornithologist and evolutionary biologist at Yale, argues that female birds choose their mates (a process called sexual selection) based on beauty- not because an attractive appearance reflects underlying health and fitness, but for the sake of beauty itself.  This is a challenge to the mainstream understanding of natural selection.  As proposed by Darwin, good genes encoding beneficial physical traits, such as speed and strength, increase survival and are therefore more likely to be passed on to the next generation.  It seems to me that selecting mates by their beauty, which does not help birds fly faster, hunt more successfully or detect predators better, may actually dilute survival of the fittest.  On the other hand, among humans, an expensive suit and large blond comb-over may attract potential First Ladies, so cosmetic appearance can be a Darwinian advantage!

As we evolve in the Information Age, survivability becomes further and further removed from what our genomes dictate.  With the aid of prostheses (eyeglasses are an early example), medical advances, internet avatars of ourselves (no, not just online dating services), and of course robots, survival is now vastly multifactorial.  And we’re just talking about surviving to childbearing age.  Our physical deficiencies have become less crucial to our chances of having offspring, whereas a nearsighted, clubfooted caveman would not have survived long enough to attend the Junior Prom.

In light of this departure from Darwin, perhaps my characters in Fourth World are too humanoid.  In 2196, people may be closer to moles on wheels:  inarticulate, nearly blind, not beautiful in any sense, hybridized with cybernetic parts, texting one another with tiny hands but massively hypertrophied thumbs.  Bizarre, maybe- but still having kids!


Does Not Compute

What’s that nagging pain, you ask?  In today’s SF Chronicle, there’s an Open Forum piece on crowdsourcing medical diagnoses, a new and trendy way to find out what’s bothering you.  Patients submit their symptoms to an online forum of diagnostic enthusiasts, some of whom are medical professionals, and they respond with a list of potential diagnoses, the most popular one listed first.  Imagine Wikipediatrics.  Or Family Practice Feud (“our survey said…?”).  Any set of symptoms or data will generate a bell-curve of answers, and the theory is that the peak of the curve is most likely to be correct.

My first reaction on reading this was to choke on my coffee.  As a rheumatologist, I was impressed by how many diseases in my field present with almost exactly the same constellation of symptoms:  for example, fever, joint pain and rash.  Much more testing is usually needed, and even then, the power of every test is limited by its sensitivity and specificity.  For decades, I taught medical students and residents about the importance of subtle variations in the patient’s history and physical exam which could lead to the diagnosis and treatment, even in the face of contradictory and misleading test results.  To steer through a complicated landscape, it helps when the physician is dedicated not just to finding the answer, but to the larger goal of helping the patient.

Dr. Lisa Sanders, who teaches at my old medical school, has a column in the NY Times Sunday Magazine, in which she presents a challenging diagnostic case weekly.  Based on her description of history, physical and preliminary tests, readers suggest possible diagnoses.  And, predictably, the suggestions are all over the map:  remember, many diseases look remarkably similar!  Now this crowdsourcing of diagnoses brings the whole enterprise to a different level- for a fee, of course.

There is an analogy to how the practice of medicine is currently evolving:  diagnosis by computers.  Given a set of symptoms, a diagnostic algorithm can pop up a set of answers, with the most likely one on top.  But the old expression “Garbage in, garbage out” applies when subtle points of the history and physical are passed over, or when irrelevant data are swept into the equation.  Someone still has to decide what data to enter or leave out, and wouldn’t it be better for that person to have expertise, judgment and the goal of not just finding the answer, but the larger goal of helping the patient?  In other words, a good (non-cybernetic) doctor?

Here’s an excerpt from Fourth World, in which an intern, Kai, presents a puzzling case to his attending, Dr. Hol Chan:

Kai continued, “I have put W.P. through the Probot twice, and both times the results were identical:  signals of tissue injury or regeneration, inflammation, pre-mutagenesis and metabolic derangement are completely absent.  Epigenetic expression, including at the micro-RNA level, is normal.  Risk loci mapping and haplotype structure are unremarkable.  You can see on the next screen that the central and peripheral chi are not in any way obstructed.  I entered the patient’s history, systems review, family history, physical exam and lab data into the analyzer and found no matching diagnosis.  And so, without a suitable coding of his diagnosis, there is no way to initiate the billing process.”

Dr. Chan, studying the wall screen, nodded in agreement.

Kai looked up from his da-disc and shrugged.  “In fact, W.P. is perfectly healthy, even though obviously he is persisting in his illness behavior.”

W.P. stared fixedly downward at his legs, now pale and mottled in the cold room.  Unsure what “illness behavior” implied, at least he knew that his pain was very real.  It was excruciating, every minute of every day; the sleepless hours of each night passed exquisitely slowly…  His wife finally shattered the silence:  “Healthy? Perfectly healthy?  What are you talking about?  Can’t you see he’s in pain?  What’s perfectly healthy about that?  Can’t you just rearrange his genes and end this once and for all, instead of giving him all those… those therapeptides to control pain but only make him more lethargic than he already is?  You doctors and your damned machines:  scanning and probing here and there, coming up with nothing.  Epigenetic expression is normal.  Oh, so everything’s just fine then, is it?  Well it’s not, and I am at the end of the line, people!   I can’t stand it anymore- you find the problem, and you find the solution…you find it.”  She suddenly began to sob, her shoulders shaking, her arms folded tightly across her chest.

Kai had panic scrawled on his face.  “But the Probot is accurate within ten-to-the-minus-seven-percent!  As I said, there’s nothing wrong with your…”  Dr. Chan cut in abruptly:  “Kai.  Excuse me.”  Then, addressing everyone in the room, she said in her most calming voice, “I think we’d better break here, and collect our thoughts.  Why don’t we go to the conference room and review our findings?

“If you don’t mind,” she said to the patient’s wife, who had just as suddenly stopped her crying but shook her head slowly back and forth, unwilling to accept that she and her husband were going through this yet again.