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[Comment] Offline: Prescriptions for an Age of Apprehension

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The Lancet was founded (in 1823) at a strange historical moment. Among progressive politicians and intellectuals, there was acute disappointment that the Enlightenment had seemingly delivered only grinding destitution, workhouses for the poor, and crowded debtors' prisons. But, paradoxically, there was optimism too—a growing movement for social and political reform. A spirit of human sympathy and feeling was emerging. The Romantic movement, exemplified by William Blake's crusade for imaginative redemption from the “heaven of our misery”, was revitalising the hopes of (and for) society. Today is a similarly strange moment. We live at a time of extraordinary political turbulence. Doubt and uncertainty are daily companions. Assumptions that anchored our beliefs are being torn apart and incinerated. Yet we are demonstrably living in an ever healthier world. Another paradox. As Hans Rosling identified, the western mind prefers a pessimistic perspective. Hans called it our “overdramatic worldview”. “Though the world faces huge challenges”, he wrote in Factfulness (2018), “we have made tremendous progress”. Steven Pinker put it this way in Enlightenment Now (2018), “We will never have a perfect world…but there is no limit to the betterments we can attain if we continue to apply knowledge to enhance human flourishing.” Indeed, in medicine we have reasons to be enormously cheerful. Discovery science is rewriting our understanding of human disease. Randomised trials are delivering astonishing innovations to clinical practice. And thought leadership has redrawn the contours of political concern for mental health, maternal and child survival, and climate and health.

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But there are shadows. Dark shadows. Steep disparities within and between nations are excluding hundreds of millions of people from the successes enjoyed by a few. Political leaders are creating hostile environments that set citizen against citizen. There has been a slow but palpable loss of solidarity among communities, among peoples. The consequences have been electoral results in democracies that threaten our security and repressive policies in authoritarian regimes that are erasing liberties. In this Age of Apprehension, it is worth recalling therefore, to follow Rosling and Pinker, our spectacular strengths. Palaces of knowledge that we call our universities. National (and increasingly universal) health-care systems. Political commitment to development assistance. Professional associations for health workers and our scientific academies. Life science industries. The diversity of civil society. (And perhaps even our scientific journals.) But to remove the dark shadows cast over us, we have to change. Collectively, we have been too complacent, too self-congratulatory, and too parochial. We have let our societies down.

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First, we must recognise, protect, and nurture our strengths. We don't fully appreciate the gifts we have inherited. Second, we must see health, global health, and medical science as national strategic assets. Today, we don't. These activities are seen as less important than trade, defence, and financial services. They are not. Third, we have to be more ambitious. Despite the justifiable hopes of Rosling and Pinker, the many dangers we face are real and growing, from ecological catastrophe to geopolitical rivalry. We cannot be satisfied with stasis. Our comparative advantage is that we preside over powerful means to influence, advise, and guide through science and evidence. Fourth, we must sharpen our advocacy. Too often, we choose to be collegial with political power instead of resisting, opposing, and challenging that power. And finally, we must do more to coordinate our strengths. We operate as independent entities—universities, research funders, journals—thereby missing opportunities to forge alliances and partnerships. One final point. We have forgotten our origins. The Enlightenment was born in 1633 (yet another paradox) when Pope Urban VIII condemned Galileo for defending a heliocentric view of the universe. Out of that momentous reversal came the first work of Enlightenment—Descartes' Discourse on Method (1637). That work mattered not only because Descartes set out a means “to distinguish the true from the false”. It was important because Descartes was the first modern philosopher-scientist to connect knowledge with ethics. The “search for truth” was not an end in itself. The end was truth through reason and a “moral code”. Truth matters only to the extent that it is put to moral work. A balm in an Age of Apprehension.

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