Reading 2022

  1. The Dawn of Everything: A new History of Humanity. David Graeber and David Wengrow.
  2. The Frontiers of Knowledge: Whaat We Now Know about Science, History and the Mind. A.C. Grayling.
  3. Unwell Women: A Journey Through Medicine and Myth in a Man-Made World. Elinor Leghorn.
  4. Greek Myths: A New Retelling. Charlotte Higgins.
  5. The Falcon Thief: A True Tale of Adventure, Treachery and the Hunt for the Perfect Bird. Joshua Hammer.
  6. Red Thread: On Mazes & Labyrinths. Charlotte Higgins
  7. The Age of AI: And Our Human Future. Henry Kissinger, Erica Schmidt and Daniel Huttenlocher.
  8. H is for Hawk. Helen Macdonald.
  9. Lost in Thought: The Hidden Pleasures of an Intellectual Life. Zena Hitz.
  10. The Long Way to a Small Angry Planet. Becky Chambers.
  11. A Closed and Common Orbit. Becky Chambers.
  12. To be Taught If Fortunate. Becky Chambers.
  13. Record of a Spaceborn Few. Becky Chambers.
  14. The World we Create: From God to Market. Tomas Björkman.
  15. The Galaxy and the Ground Within. Becky Chambers.
  16. Bildung – Keep Growing: Report to the Club of Rome. Lene Rachel Andersen.
  17. The Cat Who Saved Books. Sosuke Natsukawa.
  18. Klara and The Sun. Kazuo Ishiguro.
  19. The Weirdest People in the World: How the West became Psychologically Peculiar and Particularly Prosperous. Joseph Henrich.
  20. Three Epic Battles That Saved Democracy: Marathon, Thermopylae and Salamis. Stephen P. Kershaw.
  21. Powers and Thrones: A New History of The Middle Ages. Dan Jones.
  22. Persians: The Age of The Great Kings. Lloyd Llewellyn-Jones.
  23. Philip & Alexander: Kings and Conquerors. Adrian Goldsworthy.
  24. Nomads: The Wanderers who Shaped our World. Anthony Sattin.
  25. The Bird: The Great Age of Avian Illustration. Phillip Kennedy.*
  26. The Story of the Jews: Finding the Words 1000 BCR – 1492 CE. Simon Schama
  27. Elektra: Jennifer Saint
  28. Ithaca. Claire North.
  29. How Birds Work: An Illustrated Guide to Form and Function – From Bones to Beak. Marianne Taylor.
  30. Bird Anatomy for Artists. Natalia Bali.
  31. Homage to the Bird. Greg Oatley (manipulated hyper realistic digital images.
  32. Stone Blind: Medusa’s Story. Natalie Haynes.
  33. The Botanical Illustrator’s Handbook. Sally Pinhey.
  34. If I Understood You, Would I Have This Look on My Face: My adventures in the art and science of relating and communicating. Alan Alda.
  35. Living Planet: The Web of Life on Earth. David Attenborough
  36. The Art of Botanical & Bird Illustration: An artist’s guide to drawing and illustrating realistic flora, fauna and botanical scenes from nature. Mindy Lighthipe.
  37. Werner’s Nomenclature of Colours, Adapted to Zoology, Botany, Chemistry, Minerology, Anatomy and the Arts. Trans. Patrick Syme
  38. Capturing the Essence: Techniques for Bird Artists. William T Cooper.
  39. Color Mixing in Acrylic: Learn to mix fresh, vibrant colors for still life’s, landscapes, portraits and more. David Lloyd Glover.
  40. A Short Philosophy of Birds. Philippe J. Dubois and Elise Rousseau.
  41. Extraordinary Birds: Natural Histories: Rare Book Selections from the American Museum of Natural History Library. Paul Sweet.
  42. Histoire des Oiseaux. Francois Nicolas Martinet.
  43. Australian Parrots. Joseph M. Forshaw, illustrated by William T. Cooper (for reference and the illustrations).
  44. User Friendly: How the hidden rules of design are changing the way we live, work and play. Cliff Kuang with Robert Fabricant.
  45. Strange Rites: New Religions for a Godless World. Tara Isabella Burton.
  46. Nature’s Palette. Introduced by Patrick Baty.
  47. Nights of Plague. Orhan Pamuk.
  48. A Life on Our Planet: My Witness Statement and a Vision for the Future. David Attenborough.
  49. Nature and Its Symbols. Lucia Impelluso translated by Stephen Satarelli.
  50. The Trials of Life: A Natural History of Animal Behaviour. David Attenborough.
  51. Medicine – A Graphic History. Jean-Noel Fabiani & Philippe Bercovici.
  52. Feather and Brush: A History of Australian Bird Art, Second Edition. Penny Olsen.

What I Listened To, Watched and Read During Year Two of the Pandemic

The teenaged members of the household are all about the Marvel Cinematic Universe – so discussion of Ragnarok and Thor occasionally comes up. This got me thinking more about the origin stories for Thor, Loki and Odin. And down a rabbit hole I went. Firstly I binged 15 hours of Wagner’s Ring Cycle via Youtube. The Ring Cycle led to watching the rest of the Wagner operas and reading Wagner commentaries from Alex Ross and Roger Scruton. Wanting to know more about Yggdrasil, the World Ash Tree, Sleipnir the 8-legged horse of Odin (Wotan) and Odin’s ravens Huginn (Thought) and Muninn (Memory) I went back to the Eddas, Sagas and the Nibelunglied. Along the way I took in Tolkien’s version of the the story of Sigurd and Gudrun. Noting some of the other sources for Wagner I then pivoted to Grail Lore and the Arthurian Romances, Parsifal. Along the way I also came across Arab tourist guides of the Rus lands – encounters with Vikings.

Some themes in these ancient and not so ancient texts:

  • beware rings that bestow absolute power
  • enchanted swords should also be handled carefully
  • also keep an invisibility cloak or identity transforming helmet available on your adventures
  • it is surprisingly easy to masquerade as a woman’s lover under the cover of darkness
  • identity theft and identity non-disclosure ends badly
  • the hero dies
  • the heroine dies
  • family: can’t live with them and can’t live without them
  • avoid garrisoning yourself in a flammable building
  • don’t make deals with tricksters and wise men

Of course there was more than this including more serious themes about power, lover and desire but the list propels the action.

I attempted to listen to a Piano Sonata everyday of the year and did so until August when Primephonic was taken over by Apple with promises of a new Apple classical music offering coming soon – in 2022. Primephonic was a fantastic classical streaming music service. It was so good because of its’ search function. You could search for a specific composer and composition and see literally every recording and how many recordings existed of a particular piece. The use of information/metadata about a classical piece on Apple Music and Spotify is incredibly poor. They also had great customer service – making timely corrections to the recording information when I notified them. Hopefully the new service will be up and running soon. Until the service shut I posted the daily sonata to Facebook and Twitter.

I came across a number of Jordan Peterson YouTube discussions with various psychologists and researchers including Brian C. Muraresku, Scott Barry Kaufman, and John Vervaeke. Muraresku and Kaufman discussed their work on transcendent experience but from quite different perspectives. Muraresku has written (see below) on the role of psychedelics in Ancient Greek ritual at Eleusis and how they were initially incorporated into the early Christian experiences. I love the ancient saying “If you don’t die before you die, you die when you die”. Kaufman approaches transcendence more from the the perspective of an update and further development of Maslow’s hierarchy of needs. I went on to read about recent research in psychadelics and transcendent, life-changing experience. The endgame hear literally is death and the failure to accept mortality – something I routinely come across in my occupation as a cancer specialist.

The John Vervaeke discovery was the real find of the year. I have finished all 50 episodes of John Vervaeke’s YouTube series Awakening from the Meaning Crisis – whilst I used the rowing machine. This series concerns the rediscovery of the ability to make meaning in life (not the meaning of life) and living in the being mode not the having mode. It traverses historical themes, philosophy, some theology, neuroscience, artificial intelligence, theories of wisdom, developmental psychology and principally cognitive science. There is a great supplementary video on the theory of zombies. I highly recommend this series which is a mini-course in mostly Western Civilisation but also strong reference to non-theistic religions of the East and their relevance to meaning making. A number of the books I read in the second half of the year are recommended through the series. The videos are on Youtube and the transcripts are here [].
A reading list is here [].

In the end Vervaeke doesn’t seem explicit about how to overcome the meaning crisis. I think this is in part because he hasn’t definitively solved the problem or at least he doesn’t wan’t to claim to have: he is very modest and self-deprecating but also as a philosopher he is loath to claim to know the truth, especially when a lot of what he discusses is the work of others. He also has the issue of distinguishing between the meaning crisis at the level of the individual and the level of society. With respect to the former he seems to advocate for the creation of flow states as per the work of Csiksentmihalyi and to create autopoetic states – to recreate the being mode. I extrapolate synergies with Camus’ Myth of Sisyphus – To Be – and also the need to accept (the) absurdity (meaninglessness) by being . At a societal level his problem is that he has provided a detailed explanation of how religion has failed to provide the meaning it once did and that it cannot revive itself and yet a community of people must embrace a religion-like ‘thing’ to overcome the meaning crisis. He hints at a non-theistic path. He has much more to watch and read beyond the series so I expect conclusions will be better articulated over time.

Aside from the above I threw in some history and political reading around China and climate change. I strongly recommend The Good Ancestor (see the reading list). For ‘lighter’ entertainment I read feminist fiction reinterpretations of the Homeric poems. These were fine and I don’t think fall into the work identified in Cynical Theories (see the reading list). Cynical Theories calls out, but doesn’t quite cancel, the problems of the extreme left views in educational institutions – reflecting the issue that some (not enough) commentators are making that both the extreme right and the extreme left use identity inappropriately and to no good end.

That wasn’t all I heard, watched, read but it’s enough to blog about. Now I need to go make some resolutions….

The 2021 Reading List

  1. Ten Lessons for a Post-Pandemic World. Fareed Zakaria.
  2. Venus and Aphrodite: History of a Goddess. Bettany Hughes.
  3. Theogeny. Hesiod translated by Barry Powell.
  4. The Offense of Love: Are Amatoria, Remedia Amoris and Tristia 2. Ovid translated by Julia Dyson Hejduk.
  5. Wagnerism: Art and Politics in the Shadow of Music. Alex Ross.
  6. The Ethics of Influence: Government in the Age of Behavioural Science. Cass Sunstein.
  7. The Story of China. Michael Wood.
  8. The Legend of Sigurd & Gudrun. J.R.R Tolkien.
  9. Cynical Theories: How Universities Made Everything about Race, Gender and Identity – and Why this Harms Everybody. Helen Pluckrose and James Lindsay.
  10. The Ring of the Nibelung. Richard Wagner translated by John Deathridge.
  11. Beowolf. Translated by Maria Dahvana Headley.
  12. The Ring of Truth. Roger Scruton.
  13. Circe. Madeleine Miller.
  14. Norse Mythology. Neil Gaiman.
  15. Sagaland: The island of stories at the edge of the world. Richard Fidler and Kari Gislason.
  16. The Prose Edda. Snorri Sturluson translated by Jesse Byock.
  17. The Saga of the Volsungs. Unknown translated by Jesse Byock.
  18. The Nibelungenlied – The Lay of the Nibelungs. Unknown translated by Cyril Edwards.
  19. The Song of Achilles. Madeline Miller.
  20. Ngal’s Saga. Translated by Robert Cook.
  21. The Norse Myths: Stories of the Norse Gods and Heroes Vividly Retold. Dr Tom Birkett.
  22. Sir Gwain and the Green Knight. Translated by Bernard O’Donoghue.
  23. Doom – The Politics of Catastrophe. Niall Ferguson.
  24. The Square and the Tower: Networks, Hierarchies and the Struggle for Global Power. Niall Ferguson.
  25. Echoes of Valhalla: The Afterlife of the Edda and Sagas. Jon Karl Helgason.
  26. Tristan, with the ’Tristram’ of Thomas. Gottfried von Strasburg.
  27. The Hero with the Thousand Faces. Joseph Campbell.
  28. Foundation. Isaac Asimov.
  29. Mauve – How one man invented a colour that changed the world. Simon Garfield.
  30. The Children of Ash and Elm: A History of the Vikings. Neil Price.
  31. Voices of History: Speeches that changed the world. Simon Sebag Montefiore.
  32. Arthurian Romances. Chretien de Troyes translated by William Kibler and Carleton Carroll.
  33. Written in History: Letters that Changed the World. Simon Sebag Montefiore.
  34. Parzival. Wolfram von Eschenbach translated by Arthur Thomas Hatto.
  35. The Pandemic Century: A history of global contagion from the Spanish Flu to Covid-19. Mark Honigsbaum.
  36. Ibn Fadlan and the Land if Darkness: Arab Travellers in the Far North. Ibn Fadlan translated by Paul Lunde and Caroline Stone.
  37. How to Change Your Mind: The New Science of Psychadelics. Michael Pollan.
  38. The Immortality Key: The Secret History of the Religion with No Name. Brian C. Muraresku.
  39. Abelard & Heloise: The Letters and Other Writings. Translated by William Levitan.
  40. Beyond Order: 12 More Rules for Life. Jordan Peterson.
  41. Transcend: The New Science of Self-Actualization. Scott Barry Kaufman.
  42. Flow: The Psychology of Optimal Experience. Mihaly Csiksentmihalyi.
  43. Transformative Experience. L.A. Paul.
  44. How to Avoid a Climate Disaster: The solutions we have and the breakthroughs we need. Bill Gates.
  45. The Dhammapada. Translated by Valerie J. Roebuck.
  46. The Good Ancestor. How to Think Long Term in a Short-Term World. Roman Krznaric.
  47. The Digital Silk Road: China’s Quest to Wite the World and Win the Future. Johnathan E. Hillman.
  48. Utzon and the Sydney Opera House. Daryl Dellora.
  49. The Harbour: A city’s heart, a country’s soul. Scott Bevan.
  50. Mortals. How the fear of death shaped human society. Rachel E. Menzies and Ross G. Menzies
  51. The Myth of Sisyphus. Albert Camus.
  52. The History of Philosophy. A.C. Grayling.

The Australian Way

“I’m very confident we can solve this,” Mr Morrison said, sharpening his re-election pitch to voters ahead of next year’s poll. “I have much more confidence based on the track record of world history that this will be solved by the entrepreneurs and the scientists and the industrialists and the risk-takers and the investors, and supported by smart regulation.” – From Rob Harris in the Sydney Morning Herald November 13, 2021

Let’s dissect this proclamation.

At least in the first statement the PM is acknowledging it won’t be him fixing the problem, what ever ‘this’ is.

Isn’t “the track record of history” a tautology?

Anyways, I am curious from what date Mr Morrison envisages this history of “entrepreneurs and the scientists and the industrialists and the risk-takers and the investors” started. Maybe the Renaissance? Or perhaps the Scientific Revolution? The spirit of the British and Dutch East India Companies comes to mind. Not to mention those brave industrialists who dug up coal to fuel their empires of train networks and steel mills.

I do not dispute that science leads to great and disruptive innovation. After all, where would Australia be if it weren’t for the need to observe the Transit of Venus.

But let’s not forget that purposeful science to overcome big problems has historically been underwritten by government before the venture capitalists became involved. Think the Manhattan Project and the Moon Landing – both in excess of 20 Billion US in contemporary currency. The Human Genome Project in excess of 3 Billion Dollars. Military applications led to many innovations like the internet – think DARPA. Closer to home CSIRO brought us wifi. Much biomedical research starts in government funded university labs before biotechs and pharmaceutical companies pick up the patents.

Promises of 500M to 1 Billion AUD don’t add-up to much when you compare the ‘moonshot’ projects. Even when you use other comparisons like the percentage of Australian GDP, the cost of running a larger Australian Hospital each year (about 400-500M) or the size of the Australian poultry industry (about 850M) the sums Australia are committing are tiny.

Finally, what is “smart regulation”? Mr Morrison has already said that Australians are sick of mandates – especially those coming from Labor. Smart almost certainly doesn’t mean evidence-based. That would mean following the science…..oh I forgot, the scientists are going to save us. I suspect smart regulation are regulations that don’t increase taxes and ergo reduce votes.

Weasel Words – they’re the Australian Way.

Some Musings on the Metaverse

Last week the CEO of Facebook, Mark Zuckerberg, announced a rebrand and new direction for social media company. The company named Meta will develop the metaverse….the what-averse you ask? Kevin Roose in the New York Times (Oct 29, 2021) summarises: “Mr. Zuckerberg painted a picture of the metaverse as a clean, well-lit virtual world, entered with virtual and augmented reality hardware at first and more advanced body sensors later on, in which people can play virtual games, attend virtual concerts, go shopping for virtual goods, collect virtual art, hang out with each others’ virtual avatars and attend virtual work meetings.”

The metaverse would use virtual and augmented reality (VR/AR) technologies already in existence but with the expectation that there will be considerable advances that would allow individuals to be completely immersed in the other worldly experience and potentially all the time.

VR/AR has some great applications outside gaming. These include simulation for healthcare training and therapeutic applications in mental health like treatment of anxiety disorders, particularly those that include phobias or situational distress.

But despite the cool factor of VR/AR we aught to cautious and learn from the past. The meta verse simply amplifies the actual harms of social media.

So run this thought experiment – what is Facebook’s product? If you think it is an app to allow friends to interact with each other your are wrong. Facebook is an algorithm driven network designed to facilitate behaviour change to the benefit of paying advertisers who do not just want you to buy stuff but also vote for Governments. Meta, the company formerly known as Facebook, is the poster-child for Shoshana Zuboff’s surveillance economy. Machine learning sends you content and you react.

The metaverse is social media on steroids. Much has been written about the way social media, in particular Facebook, produces echo chambers. People are streamed what Facebook thinks they are interested in, so reinforcing belief systems. This can only have a stronger effect in a metaverse because a metaverse does two things simultaneously: it embeds you in an alternate reality that caters to your capacity for self-deception (aka., bullshit) whilst divorcing you from exposure to actual reality.

Actual reality is what people need and crave. COVID-19 lockdowns prove that people want real not virtual experience. In stating this I do not wish to imply there should be no VR/AR…working from home is a game changer, but I don’t think anybody would trade a real experience to a virtual experience unless their real experiences were seriously deficient.

On the latter point, is there any way of justifying a metaverse. I think there is but it hinges on an analogy that is already being explored in medical/scientific circles. What if VR/AR can produce transcendent experiences in the way that psychedelics can? By this I make an assumption that the reader accepts the evidence that psychedelics can produce transcendent experience. If VR/AR can do this then it may be worthwhile but if it is truly able to do it then there is a paradox….the transcendent experience, at least on psychedelics, is not addictive. It might be replicated over time but those that experience transcendence are not addicts after the events. It would be in the interest of Mr Zuckerberg not to achieve this as it would be disadvantageous for his stock price.

The fact that VR/AR can be used for therapeutic purposes in mental health is a canary in a coal mine. It means that these technologies can also be harmful and in a way that makes current social media look primitive.

From a surveillance capitalism perspective we must also recognise that the metaverse is going to rely on more than just your posts to generate the profiles it needs to make money. In the metaverse your biometric data will be in the Facebook/Meta cloud waiting to be exploited.

I have no objection to Facebook rebranding and redirecting as Meta but as a society we need to start exploring how we regulate this now, not once we realise we are in a dystopian version of Ready Player One.

Oh, and by the way, the blockchain and AI needed to power this metaverse is definitely not environmentally friendly.

The Mindset to End Australian Lockdowns

Currently Australia, or at least New South Wales and Victoria are in the midst of continuous or rolling, recurring lockdowns. For Sydney this is the first real surgery of the COVID-19 pandemic having largely been successful at transmission suppression in the time prior to Easter 2021. The reason is the emergence of the delta variant of COVID-19 just at the point when the Australian vaccination campaign was being implemented. Due to the tyranny of distance vaccine distribution in Australia was delayed whilst Europe and North America received their shots. During that time vaccine hesitancy, or more specifically Astra-Zeneca hesitancy, became common due to the emergence of a low probability but potentially fatal coagulation disruption called VIPIT. Pfizer was not yet available and the medical communicators were equivocating. Meanwhile the delta variant was arriving by plane and evading hotel quarantine. This variant seems more transmissible, possibly due to higher viral load in the infected, and appears to cause more serious illness in younger individuals than earlier variants.

The Australian Government and the NSW Government have indicated lockdowns will not be needed once 70% of the population are fully vaccinated. This should occur, with current vaccination rates, towards the end of October 2021. What is the significance of the 70% target. The United Kingdom is the example to note. At approximately 75% of the population over 16 years of age fully vaccinated the UK is still experience a surge of cases of around 30K per day – roughly half the peak at the start of 2021 and predominantly driven by delta. Most of the cases are unvaccinated or partially vaccinated although some breakthrough cases are occurring. Notably the risk of hospitalisation is reduced and the number dying each day is <100 (counting deaths that occur within 28 days of diagnosis. This is versus a daily death toll that peaked at 1800.

To date the Australian approach seems to have been to pursue freedom through perfection: tight border controls, zero local cases and zero transmission. This has been achieved with snap lockdowns, masking, etc. Even more perfect that Australia has been New Zealand, which is even more remote from the rest of the world.

Australia and New Zealand cannot remain islands unto themselves forever and they can’t stay locked down forever. From a practical perspective it is actually unknown at the current time whether or not the current lockdown settings or any lockdown settings are strong enough to suppress a delta variant outbreak. Based on the current situation in the UK and making a major assumption that the situation won’t deteriorate due to waning immunity or the emergence of a even more virulent and transmissible variant, Australia will need to get used to living with the presence of COVID-19 if it is going to relax lockdown.
Living with endemic COVID-19 means that despite high vaccination rates and herd immunity due to the combination of vaccination and infection/exposure individuals will become infected, most will have milder illness but there will still be, based on the current UK experience, hospitalisations and deaths.

Let’s assume 70% vaccination is by the end of October and true to the word of the politicians the lockdown is lifted and internal borders are opened – then what? Well in 10 WEEKS the Australian healthcare system needs to be able to accomodate a manageable number of hospitalisations and ICU admissions AND be able to conduct as much business as usual activity as possible. If we are unable to re-open the healthcare system then either the lockdowns don’t end or the whole situation needs re-thinking.

The other part of the mindset that will need to change is that we will need to accept that there will be some deaths. Australia is fortunate that there have been no influenza death for 12 months. This is not the norm and in a cyclical fashion Australia regularly has in the order of 1000 deaths per annum. This may be where we land with endemic COVID-19. The current influenza mortality rate is due to a combination of the local measures put in place to fight covid, rigid border control and ongoing vaccination programs. It is implausible that we will reach a state of no deaths from COVID-19 even after herd immunity is achieved so we need to learn to live with some poor outcomes.

Overall, and despite the current surge, Australia has been relatively good at responding to the pandemic. Where Australia has failed is planning adequately for the short and medium term future, implementing some of the plans (like vaccination) and in becoming complacent when things were going well. Now that things aren’t going well it is time once again to move at pace and scale to ensure the resilience of the healthcare system beyond October and to develop effective communications strategies to that the public knows where the ship is sailing to and that sometime we need to change tack.

Time for America to Look in the Mirror

America is in chaos.

Simplistically this is about a personality, Trump, claiming the priorities of his ‘populist’ base.

But this is too simple.

America was founded on a promise and a dream….truths self evident that all men are created equal.

And yet many of the people believed and continue to believe that all men are not equal. And in particular some men are inferior – those inferiors being blacks, women, gays, non-Christians, the impoverished and the like.

And yet, America also promotes the notion that it is the land of opportunity. Anybody can rise to success and wealth off the back of their own sweat and perseverance. This is not true. The USA has low rates of moving upwards in socioeconomic terms and the the reasons include a false meritocracy and a local of true equality.

I spent some months in the USA in the mid-1990’s and attended lectures at an esteemed mental health faculty. The message I took away was that America actually doesn’t care about the mentally unwell or to be more specific, the underprivileged, the poor.

And so, I can only conclude, that equality and individualism as ideals are incompatible bedfellows, especially when greatness is founded in bigotry.

And so we are left with a Capitol stormed by agents of chaos. They seek their own order but bring no organizing principles.

Ironically the Congress, House and Senate, are now tasked with recovering from COVID -19 and a brave new world where the ‘base’ is the underclass and they will and demand and the very same social supports that they deride as socialism.

I don’t know where the USA should go from here but it must re-invent itself and perhaps it should start by looking in the mirror and conducting a reality check.

Oncology After the Pandemic

One of the questions in response to the blog post was what would be the impact on oncology?

The impact on COVID-19 on oncology may vary quite a bit from country to country depending on the degree to which the healthcare system coped: in some countries there have been huge impacts on presentations with cancer and in some cases the ability to provide timely treatment. Where I work, in New South Wales, Australia, there has been negligible impact on the new cancer notifications and little reduction in the capacity to provide care.

The first major observation is that the pandemic acts as an accelerant driving change that was already happening in healthcare. The most obvious change is in virtual care including telehealth. When the pandemic starting impacting healthcare services activities in virtual care that had been trundling along with pilots and limited implementations over a decade were suddenly scaled up and implemented in a matter of weeks. In Australia, telehealth was ultimately catalysed and embraced by the medical community when fee-for -service arrangements were recognised after many failed years of lobbying. The systems aren’t perfect but they are now here to stay.

The acceptance and adoption of telehealth-related technologies including both software and (mobile) hardware enable a number of important activities that are useful in oncology. It can provide capacity for home-based care, particularly when monitoring is required. Being able to detect a deteriorating patient at home when they are being treated for specific conditions allows for rapid intervention. There will be increased capacity for shared care with primary care physicians and both in the treatment and survivorship phases of care more care can be delivered in a virtual fashion. Enhancing the ability to provide 24/7 care is particularly important for patients receiving palliative and terminal care.

Capturing patient reported outcome measures (PROMS) as well as patient reported experience measures (PREMS) is a high priority in the field of oncology as this has been shown to improve symptom management and oncologic outcomes, potentially reduce costs of care, and also can enhance the patient experience. In a virtual care environment PROMS and PREMS potentially become even more important as they can be incorporated into the workflow of a telehealth consultation to capture information that in turn guides the clinician as to how to direct the consult.

The response to COVID-19 in oncology/haematology led to rationalisation of care protocols for many situations. In oncology and many other fields a lot of unnecessary care was identified and suspended at least temporarily. The classic example is fractionation regimens in radiation oncology. Shifting to hypo-fractionated regimens is a much debated area of clinical variation in routine care but once there was a need to minimise patient visits to healthcare settings and to ration linear accelerator time it made instant sense to adopt such protocols. Whether or not these changes will stick will depend on time. Fortunately the impact in terms of outcomes can also be monitored via cancer registries.

One of the observations I made in my practice was that at the time there were restrictions on visiting hospitals and lockdowns were in place some of my patients re-considered their goals of care and decided against active treatment in favour of quality of life at home. The pandemic has re-ignited the need to have goals of care discussions and establish advanced care directives.

The biggest logistic challenge cancer services face is a consequence of the successes of new cancer therapies over the last 30 years and in particular the last decade. Essentially all common cancer types and many rare cancers have effective 1st-line and 2nd-lines of therapy and in some cases many more. In cancers like breast cancer screening, early detection and highly effective adjuvant therapy have increased the numbers in survivorship care. Many incurable/metastatic cancers now can be chronic disease with many patients living for years with cancer and the burden of treatment. Many of the treatments aren’t low toxicity treatments that can just be taken at home. Often the therapies are intravenous and repeats fortnightly to monthly for long periods of time. This has lead to a substantive increase in activity both in terms of visits to cancer specialists and visits for treatment. This growth in activity is not sustainable without having impacts on patient care such as increased waiting times which in their own right result in inferior outcomes.

Addressing the increased activity could be addressed by increasing resources but this is not likely to happen. Investment will be in physical infrastructure to boost the economy and the prospects of politicians. We will need to take many of the learnings from the pandemic to manage this problem. This will include development of novel models of care that exploit virtual care and in closely looking at what is necessary care versus optional care, how the care is delivered and by whom. Reducing arguably unnecessary follow-up of probably cured patients to free-up resources for chronic care cancer needs to be considered.

Oncology, as a subset of the whole healthcare system, will change long-term in response to COVID-19 but these changes were already happening and we haven’t been wasting the opportunity of a good crisis.

What will a Covid-19-Endemic World Look Like?

Everybody is hoping that towards the end of 2021 COVID-19 vaccines will have completed roll-out and we can hit the reset button turning back to life in November 2019. We’ve been through the initial panic then the realisation that the pandemic is a 1 to 2 year event. But wait, there’s more. Virologists anticipate that SARS-CoV-2 will become endemic. This means it will always be present in our communities. This is not unlike the many other coronaviruses that are endemic causing milder conditions such as the common cold.

The vaccines, to date, do not prevent transmission but do reduce the severity of disease if required. It is plausible that herd immunity will not be reached despite widespread natural infection and extensive vaccination programs. People will still become infected and the vulnerable populations such as the elderly, those with chronic disease and those with compromised immune systems will still be at greater risk of severe illness and death. So what should this mean for how we live in 2022 and beyond?

In considering this question we should consider viral influenza. Influenza as an illness poses a significant burden on the healthcare system due to the moderate symptom burden and some mortality in similar vulnerable populations as SARS-COV-2. SARS-COV-2 may have a higher case fatality rate although this may have reduced with improved understanding as to how to manage these patients. The greatest problem COVID-19 has created in regions with high rates of infection has been the burden placed on the local healthcare systems. Once intensive care beds are fully occupied by COVID-19 patients and less acute beds are also occupied the usual emergencies are competing for care and elective surgery and medicine is cancelled. Diversion of resources means other serious conditions aren’t treated.

So the endgame in a world for endemic SARS-COV-2 is to avoid shut down of the healthcare system. The caveat to this aim is that we must also find a way to avoid complete shutdown of the healthcare system without the trade off of completely locking down everything else – somehow daily life must go on. How is this to be achieved?

The first issue will be to change the mindset from crisis mode to a new business as usual mode. The current state of play in Australia is a very strong focus on public health strategies such as widespread testing, contact tracing, isolation of cases, quarantining of travelers and closed or restricted borders. The more extreme measures such as hotel quarantine won’t be sustainable if there is any intent to re-open for international tourism. There may need to be test-to-travel and proof of vaccination requirements if mass global movement is to resume.

Vaccinate as many people as possible and use every behavioral economic trick in the book to get people who don’t want to get the vaccine to do so. Altruism for the rest of society seems to be the answer. We also have to remember it is early days and there is uncertainty about the durability of the response to the vaccine but also whether there will be sufficient mutational variation to result in a COVID-20, not unlike the need to regularly update the influenza vaccine. Vaccination may need to be annual – we probably won’t know until next year

General measures to improve hygiene need to stay in place even if people are reassured that things are under control. This might mean that masking on public transport becomes routine: it was very common in Asian countries to use masks on a routine basis after previous coronavirus outbreaks. Perspex shields in customer service settings will continue. QR code check in, temperature checking and even facial recognition in less privacy concerned societies may become the routine as a way of facilitating contact tracing for positive cases. Risk minimization should prevail. Two hundred years after Semmelweis it might be time to take handwashing seriously. And other measures like proper use of PPE, not to mention the ability to make it locally.

There are going to be seismic societal changes. There are many displaced, unemployed workers around the globe. Sadly, the pandemic has taught us that many of these workers were not essential. Many work settings are getting by with fewer workers. Automation is coming into play: people still shop but they do it online and in turn the warehouses, despite some uptick in human employment, will increasingly rely on robot-based contributions to the supply chain. Drone or autonomous vehicles will start to appear on the roads. Initially these may simply serve as delivery services, replacing the e-bike powered food delivery services that currently navigate the roads with a death wish. Eventually autonomous vehicles will be driverless taxis providing a form of iso-public transport.

The lack of jobs for low-skilled and even some high-skilled people will mean a re-thinking of the welfare state. There may be a further decline in the middle class and an overall increase in inequality. Universal basic income may be not be imminent but more experiments with such societal support will occur. Regardless of the form it takes there is likely a need for increasing government supported social safety nets such as healthcare. This will mean governments will need to review and reform taxation. Note as well that society will be increasingly cash-less.

Work itself will change. Working from home will be increasingly accepted as an option for those whose jobs essentially involve screen time . Widespread broadband, 5G then 6G, team collaboration software and videoconferencing software and hardware are starting to come together to provide a more seamless experience. Working from home can provide a better work-life balance paradigm – providing of course the kids also don’t have to be at home to school (although more blended learning experiences may be offered). Productivity rather than hours may become a better metric for the output of labour especially as some companies move to modified working weeks like the 4 day week.

Live entertainment will also change. Film studios are moving to direct release to streaming and going to the cinema in person will mostly be for ‘event’ movies that benefit from the larger screen format. The trend to boutique cinema experiences will continue. For the theatre and live music, in particular for shows that are not long-runs or stadium events, there will be the public expectation that live-streaming will be available and that there will be the ability to replay at home for time-limited periods. Already such subscription services are rolling out. At at the classical concerts there will be less coughing between movements.

Other experiences like dining out may also change. Design of dining spaces to facilitate physical distancing will become more common and in places with favorable climates al fresco dining will become more common. This in turn will impact street design with broader sidewalks or other more pedestrian friendly designs.

Healthcare will be catching-up to other digitized service industries like banking. Virtual consultations and care via telehealth, remote home monitoring and many other innovations that have been brewing for decades have been given the challenge needed to implement them more quickly and in a more integrated way. The other change in healthcare will be more widespread use of rapid testing kits to diagnose many different types of infection. These will be important for rapid triaging to the right treatment and infection control measures. Rapid testing also has the potential to reduce anti-microbial resistance.

The pandemic and other natural disasters have been attributed in part to activities that result in climate change and it has also shown many people how the air can be cleaner when the world stops burning as much fossil fuel. As such the pandemic has become a catalyst for more rapid adoption of cleaner technologies. Housing has become more than ever a refuge for the world. New housing should be designed both mindful of the environment but also of the different needs of a society that goes into periods of lockdown. Having been forced to stay indoors many will have greater appreciation of the outdoors. This should prompt increased efforts to preserve and protect natural environments and also to improve urban design. Urban design will also increasingly accommodate pedestrians, cyclists, scooterists and other non-car based commuters.

Perhaps most importantly the COVID-19 endemic world needs to be ready to recognize and react quickly to the next pandemic. This is not a once in 100 year event. Pandemics or potential pandemics are occurring more frequently: think Ebola, SARS, MERS, Zika, etc. The ability for global co-operation, public/private partnerships and governments to move at pace and scale needs to be implanted in our memories and embedded into our systems. Vaccines were produced in record times. The next pandemic is most likely going to be a coronavirus sufficiently mutated and different to COVID-19 to garner it’s own name. If this is the case then vaccine development, building off existing platforms, should be even quicker, like the current status with the annual influenza vaccine.

We cannot keep living waiting for the 11 am press conference telling us how many cases there have been and what the next adjustment to restrictions will be. Now the vaccines are arriving governments need to turn to how they will manage endemic COVID-19 otherwise the light at the end of the tunnel will be the next oncoming disaster.