Editor’s Corner: 2020 Visions

David Steensma, MD
Edward P. Evans Chair in MDS Research and institute physician at the Dana-Farber Cancer Institute; Associate Professor of Medicine at Harvard Medical School; Editor-in-chief of ASH Clinical News

I have worried about the year 2020 since I was small.

My long-standing unease about 2020 and the trouble it might bring is not because it is a year in which I’m due to celebrate a milestone birthday. Although it is such a year, I try not to get worked up just because we humans happen to use a base-10 numbering system. Arbitrary events like a birthday ending in zero, a car odometer rolling past 100,000, or a new decade/century/millennium are cause for celebration – but they may also unsettle us. These touchstones underscore opportunities missed, and remind us that we are one step closer to oblivion.

Nor is my unease about 2020 because of any specific long-anticipated event – some major shift like the transfer of Macau to China, the decimalisation of the British pound, the partition of India, or Y2K. I don’t know of any one-time global event like that scheduled for this year (although there is a pretty important U.S. election in November). Instead, my sense of an approaching disaster was encoded deeply, a long time ago.

When I was a child in the 1970s, since Orwell’s 1984 was already near at hand, 2000 and 2020 were by far the most popular target dates for wild futuristic predictions. The more extreme versions were reserved for 2020. These predictions were mostly dystopian.

The year 2020 was said to be when fossil fuels would finally run out and our world would plunge into famine and chaos, terminating in gang-riddled wasteland like the desert of Mad Max. It also was the year by which a giant asteroid would surely have arrived to extinguish all life on earth, or the year food supplies would collapse so that we’d all be reduced to starvation or a diet of Soylent Green. By 2020, the “big one” would have ripped apart the San Andreas Fault and tossed Southern California into the Pacific; the resulting economic and social ripple effect would destroy the U.S. If, somehow, we had escaped all those disasters, it would only be because the technological singularity had arrived – that fatal moment when machines with positronic brains, driven by unimaginably sophisticated artificial intelligence, would find humanity obsolete and tiresome and exterminate us all.

To be fair, some pundits forecast a rosier future. By 2020, we were assured by these Whiggish optimists, robots would be doing all the humdrum tasks that humans consider drudgery. Every bit of clothing or manufactured object would be made of nanofibers or incorruptible steel, which those ancient enemies of humanity, moth and rust, could no longer consume. Futuristic technology, possibly obtained from advanced alien civilizations, would sort out problems like mass extinctions, groundwater shortages, and the residue of the inevitable nuclear winter. We might even take vacations to Mars Colony Alpha, send digital postcards from the methane lakes of Titan, or bundle our robust 130-year-old great-grandfathers into our personal helicopters to watch bionic Cal Ripken play his 10,000th consecutive game in a local plasma-ball stadium. We could commute to work via self-driving cars, where we would hardly have to work at all, except to push a few key buttons now and then, like George Jetson.

I went to religious schools from kindergarten through college, and in elementary school we had two types of textbooks, both of which were full of concerns about 2020. One group of books included dusty old hand-me-downs from the better-funded local school district. Authors of those ancient texts usually had Boston Brahmin names, followed by a Scrabble tray of lettered degrees – monikers like “W. Templeton Gardner Thorndike, MEd, PhD, LLD (Oxon; Hon).” The honorable Dr. Thorndike, along with Professor Wigglesworth, Dean Winthrop-Endicott, and all our other WASP-y betters, stared at us from behind tortoiseshell glasses in black-and-white frontispiece photos, cloaked in Brylcreem and subfusc, perhaps with an ivory cigarette holder briefly set down just out of frame.

W.T.G. “Kipper” Thorndike and his elite educator friends seemed confident that the 1964 chief exports for British Honduras (molasses) and Suriname (aluminum) were essential for suburban New Jersey 8-year-olds like me to know. Their chemistry texts labeled reactions in Gothic minuscule and cited 19th century Prussian papers, while their mathematics books underscored how important it was for every student to learn calculus and trigonometry to keep up with the Soviets, who had “just recently” launched Sputnik, threatening Cold War balance.

The other types of textbooks we used were more contemporary – often brightly colored, with curlicue hippie typefaces of the sort one might find stenciled on a chartreuse minibus full of long-haired guys with beards and guitars en route to a revival – and were mostly published by evangelical printing houses in the Midwest and South. Those books were written with an admirable earnestness and affection for all God’s children but warned us about a different type of impending Apocalypse – one that we could prepare for by committing long sections of Scripture to memory.

The resulting potent brew of fatalistic worldviews and rote learning, without an understanding of why anything was important, turned out to be terrific preparation for studying microbiology and memorizing the Krebs cycle in medical school.

As 2020 dawns, I am grateful to still be alive and to have the chance to see how this scary year unfolds. Early indicators are that both sets of textbooks were right, at least in the sense that this is an extraordinary and unprecedented time.

Were they alive today, the 2020 Cassandras from decades ago would certainly see evidence that their pessimistic prophecies are being fulfilled. We are living in a turbulent era of climate change, mass extinctions, terrorism, refugee and humanitarian crises, human trafficking, random gun violence, and global economic and social instability, accompanied by an unexpected resurgence of xenophobic nativist populism. Too many people around the planet are slouching through a grim present, with even poorer prospects for the future.

For physicians, our jobs do include a high proportion of pushing buttons. This sounds easy, but there are thousands upon thousands of buttons to push. We call these buttons the electronic medical record, and it saves us no time, takes us away from patients, and stresses us out. While George Jetson feared only a call from his volatile boss Cosmo Spacely, we answer to an endless list of faceless acronyms: JCAHO, ACGME, OHRS, IRBs, CROs, CTEP, CMS, ABIM, etc.

But also: what a heady time it is for technology and for medicine, science, and hematology! The smartphone in my pocket contains more raw computing power than the entire planet did in the year I was born. Social media and email instantly connect us all, for better or for worse. Self-driving cars seem close to reality, 3D printing is everywhere, and private companies launch recoverable rockets into space.

As hematologists, we can do multidimensional, single-cell analyses and high-throughput massively parallel combinatorial -omics, create increasingly informative animal models of disease via precise gene editing, and conduct highly sophisticated in silico experiments. In the clinic, gene therapy is (finally!) a reality for hemophilia, thalassemia, and sickle cell disease – and for hemophilia, currently available drug therapy is so good that it’s not clear we even really need gene therapy. There are dozens of tyrosine kinase inhibitors approved for hematologic cancers, as well as recombinant growth factors, bispecific antibodies, bio-engineered T cells and more. The data content in PhD theses dating from the time I was a student, which grad students required years to generate, could now be obtained in two or three days by a well-trained technician. Abstracts submitted to the American Society of Hematology annual meeting that might have been a candidate for a plenary session presentation a dozen years ago now hardly merit a poster.

Most remarkable of all, the last time I attended on my hospital’s inpatient leukemia service, there wasn’t a single patient with acute myeloid leukemia receiving old-fashioned 7+3. Every patient was either enrolled in a clinical trial – all employing drugs targeting mutations discovered within the past 10 years – or was receiving off-study treatment with one of the eight drugs approved for leukemia in the years just prior to 2020.

Will the visions of the prophets of light or of darkness prevail? None of us can see what the future holds, even though 20/20 is, cleverly, the “Year of the Eye.” We are living through the best of times and the worst of times – and it also is an interesting time, which is the most dangerous kind of time of all. As Hegel memorably wrote, “World history is not the ground of happiness. The periods of happiness are the empty pages.”

Whatever happens in 2020 and the years to follow, if it influences the practice of hematology, you’ll read about it in ASH Clinical News. May we and our leaders have the vision to steer humanity away from the big events that make headline news and toward Hegel’s blank pages of gentle progress and harmony.