Honorary Member of the Romanian Academy, Fellow of Royal College of Physicians
Professor of Internal Medicine and Gastroenterology at the University of Medicine and Pharmacy "Grigore T. Popa" Iasi, Fellow of Royal College of Physicians
Today, medicine retains the same significance, and is answerable to the same formidable criteria it has always been. On an ideational level, medicine must soothe, heal, prevent and limit the spread of disease. At the grassroots level of the individual practitioner, the idealized goal of medicine neatly fits within the above-mentioned precepts. The reality of medical practice is subjected, organized, legislated, contracted and evaluated by governing bodies on the grounds of its organizational model and its financing regulations, and its performance is profoundly affected by how much is effectively invested into it, by how much the state can afford (either practically or ideologically) to invest into its systems. In Europe, healthcare systems carry a clearly defined social valence, irrespective of the right or left-wing governments in power at a specific moment; here, the medical act is accessible to all in need. In the United States, the organization of healthcare is predicated upon an intrinsically capitalist model, and the repeated attempts to “socialise” healthcare have constantly been answered by heavy resistance from both politicians and, to a certain extent, the general population. Therefore, to speak of medicine after the pandemic requires us to tackle all levels that define medicine itself: science, in a state of constant progress which changes the foundations of the medical act every few decades; medical practitioners themselves; the healthcare system within the country under review, its population and demographic characteristics (in some countries, an aging population drastically alters the approaches needed), as well as the specific risk factors in the area and, of course, the influence of “black swan” factors such as the current SARS-CoV-2 pandemic.
Simultaneously and universally, the pandemic has occasioned an abrupt and unexpected meeting with the looming threat of disease and even death. A reality hard to conjure only a short while ago has now been made acutely apparent: developed societies with theoretically solid healthcare systems, boasting “cutting-edge” medical developments and innovations, were unable to handle the pandemic. Overcrowded hospitals, severely overstretched intensive care units, hysteria, entire stadiums transformed into morgues, have all created a truly catastrophic image. By numbers, perhaps, the crisis has not been as profound as is percieved. Death rates only exceeded 3% in a handful of countries. National governments took drastic measures to restrict civil liberties, measures which, in general, were accepted by the broader population without too much issue. The fear of disease, of death, efficiently shackled public perspectives. Hospitals limited their activity to COVID-19 cases and ER. In but a moment, the act of healthcare provision was both greatly reduced and profoundly transformed. And all this, without much outcry!
Slowly, the shock of COVID-19 dissipates, revealing a scorched battlefield in dire need of reconstruction. All sectors can speak of a post-COVID era, one that should be different, one that should reflect the lessons learned and create the premises for a sustainable and durable development that can ensure a better life for all. Reading numerous articles, books, reviews and press conferences on the topic of COVID-19 and its aftermath, we noted a tendency to believe that this crisis will indeed lead to the reformation of all existing systems and, happily, will create a positive change for good. Such wording already resembles a “wooden language”; words such as “sustainability”, “resilience”, “green energy” being repeated ad nauseam. The Solutions for Sustainable Development adopted by the United Nations can be found strewn throughout all literature discussing COVID-19.
It is true that change is now possible because, perhaps for the first time in the history of mankind (or for the second, if we consider the biblical Flood as a real occurrence which, however, left few survivors) we have seen a collective and concurrent mental preparation of the world’s 7.5 billion people owed to COVID-19, as we had to content with the imminent threat to each of our lives.
However, long has there been talk of a paradigmatic shift. The 21st century brought us into another age – at first, subtly, while later effectively “confiscating” our lives. We have transitioned from the industrial era to the digital era, without seemingly realizing and without profound social conflicts or revolution. The impact of digitization on our everyday lives was profoundly felt during the pandemic. The necessity of the Internet, the need for our digital planetary interconnectivity, of “virtual” activity in virtually all fields has truly become evident to all by now. The involvement of “digital” magnates like Bill Gates at the fore of pandemic-related discussions has fueled countless conspiracy theories. Surely, whatever more needed proving has been proven to all! Digitization is vital for survival, as it has ensured the emergency operation of the entire world during the systemic crisis caused by COVID-19 and in particular as a consequence of the drastic measures simultaneously taken by all the world’s states. Apparently, any misgivings toward this “confiscation” must disappear.
Years before the COVID-19 pandemic, Yuval Noah Harari presented the impact of digitization, of artificial intelligence (AI), of algorithms and, more importantly, of the incredible power that the algorithms’ owners had over the world. Harari was particularly concerned about the “irrelevance” facing the planetary citizen that finds himself no longer required for almost anything. Intelligent robots will be capable of carrying out almost all tasks assigned them, while algorithms will decide (and are already) the results of political elections, should those continue to be held. The need for a new social order, predicated on new values, was both stark and stringent. COVID-19 has created an opportunity for a global apprehension of this need and for the assimilation of digitization as an important, even essential, part of life. The velvet revolution had long begun; the current pandemic is merely the bloody revolution to be found at the beginning of every new era.
Returning to medicine, before the pandemic Harari described the enormous advantages of artificial intelligence in this field in particular; he assumed that should a new disease or a new type of medication appear, a World Health Organization (WHO) with access to a network of digital (AI) doctors could, in an instant, have taught and prepared them to assist patients with the most groundbreaking approaches available, an endeavour that would be impossible, or at the very least one that would take years or even decades, if implemented by real doctors. The WHO did not rise to the challenge of the pandemic exceptionally well, and everything it broadcast across the traditional avenues fell short of the organization’s actual importance. In non-academic parlance, the WHO’s response was muddled. Fortunately, it did not have digital doctors at its disposal to immediately and without question carry the WHO’s message forward and apply it to patients. Theoretically, however, digitization and artificial intelligence are valid instruments for the complete democratization of medicine, that can well help generalise the availability of cutting-edge healthcare anywhere in the world where a computer running a specific application and a network connection can be found. Of course, this is only possible in those situations where clear guidelines, diagnostic and therapeutic protocols are available. It is, moreover, assumed that a minority of active medical professionals could handle many clinical situations better than a computer could; yet, at the global level, artificial intelligence brings a series of highly desirable advantages. Once the digital age has reached maturity, it is likely that medical professionals will no longer have a place in the new system. The only space left for them would, consequently, lie in innovation, research, in exploring and broadening new possibilities. Routine work can be handled by computers. Harari also believed that effective care (nursing, caregiving) will remain a necessity, and will furthermore be in even greater demand, due to an aging population and the proportional growth of people with special needs. Recently, however, we saw the development of the robot nurse Grace, a demonstration of cutting-edge artificial intelligence (and sister to Sophia, another humanoid robot charged with conversing with the lonely, and with giving more or less successful television interviews) which was build specifically for medical care. Her facial expression mimics empathy; its gestures are designed to soothe and its motor skills make her capable of taking care of a patient just as well as a nurse, while her capacity to learn on her own and become ever more intelligent and better adapted to the needs of her patient with every passing day – just as a human might, yet unencumbered by tiredness, fear of contamination, the expected boredom owed to repeated procedures, financial or familial problems etc. make this robot into a truly ideal nurse. Their price tag is, at present, similar to that of a luxury car; yet it is estimated that once production lines are set up they will become significantly more affordable, becoming accessible to all – just as personal computers today populate every household. Harari’s predictions were surpassed by reality. It would appear that even patient care can be handled by artificial intelligence, in an efficient (perhaps even more efficient) manner, even mimicking empathy. It is difficult to imagine, to predict the effect that such an approach will have on mankind, on the human species, and what kinds of new afflictions might arise. Certainly, in the case of infectious diseases such as COVID-19, robot medical assistance can prove life-saving and, in the end, more humane than the initial approaches taken with COVID-19 patient care, where the ailing were locked away, isolated, and only visited by the minimum required medical personnel. Moreover, the aging of the global population will create a growing “market” for robots, while care homes will likely be among the first to take advantage of these developments. We cannot predict the effects such an approach might have on patient survivability rates. As practicing physicians, educated in the spirit of humanism, who firmly believe in the curative power of empathy, we have certain reservations. One particular situation comes to mind, which demonstrated the essential role of human interaction. Several years ago, general guidelines for care home residents with deglutition problems or in various stages of dementia accompanied by feeding issues too easily recommended gastrostoma procedures (establishing a direct communication between the stomach and skin, through which to insert food or nutritional solutions) in order to prevent malnutrition. It was noted that this method, despite significantly easing the provision of care (as the nurse would simply pass through and injected the patients with nutritional substances, through the gastrostoma, in under a minute) as well as helping maintain patients’ nutrition levels, was also associated with much shorter rates of survival. Consequently, gastrostoma were no longer recommended with the exception of a select few cases, and it was speculated that the teaspoon feeding of patients by nurses, a time-consuming process that required multiple gestures (wiping of the mouth, consoling, speaking, pleading, head positioning, multiple touches etc.) had a therapeutic effect. Further speculating, we can also consider that a generalized digital care model, however efficient it might appear, could well have unforeseen effects that themselves decrease odds of survival! The alienation caused by a predominantly digital care system must not be excluded from the discussion when designing new “intelligent hospitals”.
A digitalized hospital, wherein protocols are strictly adhered to (should the network not fail!) also resolves the issue of malpraxis claims, as patients would find themselves without anyone to lodge complaints against! The quality control of the medical act will still lie with those that own the underlying algorithms, or, if the state had the foresight to buy the rights to them (an unlikely situation in a market economy), subordinate to the state itself. The rights of patients will need to also be respected in the context of digitization. As physicians educated in the 20th century, with a profound trust in humanist values, we believe that existing legislation must be radically overhauled and patients’ rights redefined, in order for them to be protected from abuse, negligence and emotional trauma given the ever wider spread of digital medical care.
It is all but certain that artificial intelligence (AI) will lay at the centre of the new architecture of a redesigned medical system worldwide, and highly likely that the new system will be more cost-efficient and easier to control. The role of the patient as the primary recipient of healthcare benefits must be redefined and defended through harsh legislation. There is a real threat of alienation, of the emergence of new pathogens with a negative impact on our survival, as well as the risk of transgressing the rights of man and of the patient, in shedding control of our health and our lives to those that control the algorithms. There is a risk that we place too much trust in AI and that the medical values of life, well-being and balance will no longer be taken into account in the future. AI is capable of learning on its own, of taking decisions in order to fulfill a purpose; it cannot be excluded that it might not understand the need to alter said purpose in different circumstances; AI operates on mathematical principles, not on moral or ethical grounds. Conversely, the practice of medicine in a normal society is predicated upon ethics and morals. Quoting Kissinger, who stated that AI was the snuffing of the flame lit by the Enlightenment, we can argue that the world, at present, is not ready for such an advancement. The builders of the new digital healthcare system will ned to think of every conceivable aspect, while the medical professionals active today must take care that the traditional principles of medicine continue to be perpetuated going forward. To sit aside, to witness, to not comprehend what is unfolding, or to not care, is simply unacceptable. Physicians must have a voice when considering such drastic changes. Whether they will be successful in influencing, in shaping the new system which will inexorably come to pass, is as yet uncertain. A retrospect of the last thirty years in Romania, a time when at least one of the authors of the present paper theoretically had a great influence on the healthcare system (as Rector of one of the largest and oldest faculties of medicine in the country for over ten years, a university professor, chief of a bespoke commission assembled by the Ministry of Health, director of a research institute etc.), we come to realize that physicians’ participation in shaping the existent healthcare system was, practically, non-existent. Decisions were taken above the level of professionals who were only formally consulted, if that; their opinions mattered little. Perhaps there was one such professional who successfully asserted himself and created an emergency response system whose phenomenal power was inexplicable in comparison to the rest. We find it difficult to believe that the following years will be any different. The pandemic aided neither the system, nor the professionals. The little and divergent medical information available at the start of the pandemic failed to provide doctors with adequate tools, and over the course of the crisis many physicians were discredited. One meritorious effort is to be commended, that of the group led by Academician Victor Voicu, Vice-President of the Romanian Academy and Chair of the Academy’s Medical Department, who with great celerity published a volume synthesising the available knowledge on the COVID-19 pandemic explicitly in order to make the medical community better cope.
The experience of the pandemic and the systemic failures experienced along the way have opened the debate on the need for the state to own and to control the important sectors, vital to its survival, among them the healthcare system. Even in countries whose healthcare systems are, today, mostly private, there is talk of the need for the state to buy a majority share in them in order to adequately respond in case of a pandemic or other looming disasters. Perhaps Romania’s acceptable response to COVID-19 was also owed to its still-centralised, majority state-owned healthcare system. We must admit that the response of the Romanian State to the pandemic was good, the aftermath of the crisis, in figures, appearing favourable. It is nevertheless bizarre how, today, in an intermezzo between two COVID-19 waves, the Romanian Government again chooses to argue in favour of privatizing healthcare, of private insurance etc. It would appear that such debates have resumed from exactly where the pandemic had curtailed them. The lesson offered, then, was most certainly one not learned! Slowly, we drift back to the old-laid plans, with our decision-makers refusing to acknowledge the roil of oncoming change.
The organization of the healthcare system will also make the transition towards complete digitization and the major involvement of artificial intelligence, regardless of the misgivings we might have. It is preferrable that it remain under state control and not be doled out to private firms, whatever guises these might take. It is no less desirable that wisdom, morals, ethics and humanism are to be found in this new information and algorithm-based healthcare structure as well.
From a scientific perspective, the pandemic has offered a global premiere: the emergence of multiple vaccines in record time, two incorporating innovative m-RNA technologies. This technology, envisioned for decades by the American scholar of Hungarian descent Katalin Kariko and perfected in the last few years in an attempt to elaborate anti-cancer therapy (especially against melanoma) offered a framework for the rapid discovery of a vaccine against COVID-19. The principle of m-RNA technology consists in a sort of temporary confiscation of the protein synthesis system at a cellular level, which is instructed – by way of m-RNA – to produce non-infectious viral protein which will engender an immune response from the host. The production and testing of the vaccines lasted under a year, and were presented to mankind as a resounding success that would thwart the pandemic. The declared immunization percentages reached well over 90%, and the future suddenly appeared bright, indeed. Also developed were traditional vaccines that employ attenuated viral particles in order to induce an immune response; these showed smaller rates of immunization, but were nevertheless deemed effective. Although various criticisms were levelled during a truly global anti-vaccine and anti m-RNA campaign, the majority of the globe launched sustained vaccination campaigns, whose forerunners (Israel) hoped the pandemic had been defeated. Unfortunately, our initial enthusiasm had to give way to rising numbers of cases, culminating in the emergence of a fourth COVID-19 wave in countries with a greater than 70% rate of vaccination per population. Another lesson well-known to medicine had to be re-learned, namely that the test of time is what will determine the success of any intervention. At present, we do not know what the best vaccination strategy might be, whether the third dose will solve anything or whether we will need another vacine altogether. Unfortunately, this unexpected fourth wave in countries boasting record vaccination rates fuels the rhetoric of those convinced that vaccination was all a scam and not a medical intervention predicated on solid scientific proof. Let us hope that m-RNA technology, which has seen its fair share of stumbles in its road to maturity, will not again be shelved by unfolding events, and that the hopes of a variety of therapeutic specializations can, at last, come true.
It is expected that the next decade will see the emergence of various nanotechnologies that will change the therapeutic approach to many diseases, able to save many more lives – especially in the field of oncology. For otherwise lethal afflictions, such as metastatic melanoma, m-RNA technologies have seen engouraging results in significant percentages. It is worth highlighting, however, that if the salvation of over 40% of those condemned to a catastrophic fate can rightly be seen as a remarkable success, a 40% success rate for a medical intervention on a healthy population with the aim of preventing a disease with a maximum risk of death of 3% overall cannot. It is important that the various emerging and innovative technologies be used adequately, and their results presented in line with the expectations inferred from validated scientific data, in order to avoid mistrust and the undermining of potentially life-saving ideas.
The power of truth, and especially that of scientific truth, is incontestable. The moment error, or, worse, the denaturation of truth (either in search of profit or from misunderstanding), the consequences can be devastating. In this regard, one of the legends of the Golem appears to us highly illustrative of the power of truth. It is said that the 16th century rabbi of Prague, Judah Loew ben Bezalel, during the progrom initiated by Rudolf II, shaped an amorphous figure out of clay – the Golem, who came to life once the word emet (‘truth’) was etched on its forehead. Unfortunately, this Golem failed to achieve the purpose it was meant to serve, namely to protect the Jewish population, gained free will and started to cause mischief. The rabbi erased the letter E off the Golem’s forehead, leaving behind met (‘death’), and the creature turned to clay. The moral of the story seems to be that truth breathes life, while its denaturation brings death; moreover, we may also understand the power of the word, and the power of the story. The ways in which the media, politicians and even scientists choose to convey information and create expectations can directly inform the success or failure of any intervention. At this moment, the balance is fragile. The scientific world must make a concerted effort to honestly present data and to make populations, countries – associates, collaborators and not only the recipients of interventions that have not yet stood the test of time. This is the path towards progress and trust!
We trust that the progress of medicine will not falter, and will succeed, through daring approaches (perhaps even terrifying from a philosophical standpoint) such as genetic manipulation, m-RNA, nanotechnologies etc. to offer amelioration, cures, the extension of life by delaying old age, etc. It is to be expected that medical progress will be able to reach each patient in need in adequate time through a new hybrid system of both AI and real physicians, and that healthcare will not cause an economic catastrophe for the individual budget of the average person in need.
In medicine, unlike other fields, scientific progress has not stagnated. Peter Thiel said that we are witnessing “the ascension of the virtual world in relation to the world in which things are made”, and analyzed the evolution of technology over the past 30 eyars, reaching the conclusion that there is, indeed stagnation: all discoveries made in these decades can be traced to older discoveries made prior to the 1970s and 1908s, with no truly groundbreaking discoveries being made. Conversely, medicine and the life sciences have seen major breakthroughs, with one in particular deserving mention: the deciphering of the human genome, announced at the White House in 2000. It would appear that that decipher was incomplete, a mere beginning, with the genome’s “navigational charts” and completions being discovered later.
The COVID-19 pandemic, this planetary shake-up, has certainly led to greater introspection among individuals and societies alike, and to numerous philosophical lectures on the changing paradigms of society, medicine, economics, philosophy etc. It would be too risky to offer our own predictions. We know for a fact, however, that medicine must remain true to its humanist values, but also make use of the advancement of technology and artificial intelligence in order to fulfil its plenary purpose, namely to serve for the health and well-being of all.