COMMENTARY
NON-ZERO SUMNESS IN PEDIATRIC
RHEUMATOLOGY
My book club just finished discussing a fascinating
book that may have some pertinence to pediatric rheumatology in 2004: Nonzero: The Logic of Human Destiny by
Robert Wright (Pantheon, 2000). Wright sees a point, an arrow, and a direction
to the biological universe and to human history. Henri Bergson thought that
organic evolution is constantly driven forward by a mysterious “élan vital”, a
vital force. Pierre Teilhard de Chardin favored human history moving towards
point omega, “outside time and space”. Wright notes how both saw evolution
creating forms of life of greater and greater complexity and social structures
that have become also more impressively complex. In
contrast, Wright uses game theory to explain his view of the direction of our
world and our species, into a world of “zero-sum” and “non-zero-sum” games.
We are all familiar with zero-sum situations,
win-lose. In most governance systems, zero-sum is the primary mechanism of
electing officials and politicians. For elections of the presidency or for
prime minister of a country, someone has to win, and someone has to lose. For
elections and awards of the ACR, AAP, PRES, PANLAR, CARRA, EULAR, CPRS, APLAR,
and other organizations, some win, others lose. In the Olympics, only one
athlete can win the gold medal, others the silver or bronze. Most competitors
win no medal and in effect, lose. For class president of a school class,
someone has to win, someone lose.
Most of us are trained in that competitive mode of
zero-sum, win-lose: wars, battles, class ranking in schools, lotteries,
card-games, sports, politics, debate, contests, survival TV shows. It may be
built into our genes and, to some extent, may be necessary for our survival.
Watch our children play, compete, show sibling rivalry, and observe the
zero-sum behavior. In other situations in nature and between people and
organizations, there’s a pecking order that is more zero-sum. Who is more
important? Who has more power or
leadership skills?
So who cares? What does this have to do with
pediatric rheumatology? Let me explain. Wright would suggest that human society
and life on earth has advanced by “a kind of force-the non-zero dynamic”.
Interactions are said to be non-zero when both parties benefit. Interactions
can have both zero-sum and non-zero sum elements. A negotiated settlement
between two parties can benefit both parties, but one may get a
better-than-necessary price at the expense of the other person. Non-zero sum
interactions may more likely have the effect of both parties prospering and
working together again. But if the zero sum components are prominent, future
interactions may not be likely.
Starting with
primitive societies in the last 15,000 years, Wright maintains that humans have
utilized non-zero-sumness to derive mostly positive sums of human development
and that the area of non-zero-sumness increased over time. He describes such
cooperation/collaboration in Native American hunter-gathers, Polynesian
chiefdoms, Islamic commercial innovations, African kingdoms, Aztec justice, and
amazing early Chinese technology. This non-zero-sumness progression has been
advanced tremendously by the development of the printing press, the telegraph,
aviation, and the internet. Wright suggests that it is the accumulation of
these non-zero sumness games -- games upon game upon game - that has led to
social and biological complexity and progress in humans. This non-zero sumness
activity emphasizes non-competitive cooperation and collaboration within
societies and organizations, and between societies and organizations.
Wright also sees the same non-zero
sumness applying to biological evolution. Once life started, he suggests that
it appeared to benefit organisms with identical DNA to act “altruistically” to
each other, and eventually form multicellular organisms and later, support
groups within kin groups. He suggests that biology can be viewed as information
transfer and feedback, not unlike a financial system or an interaction that
goes on over time between scientists and inventors via letters, manuscripts,
and the internet.
With the arrival of air travel, then the internet and
globalization, the world is suddenly much smaller. We, as pediatric
rheumatologists, have an opportunity to help our patients and develop our
subspecialty locally, regionally, nationally, and internationally. I would
suggest that it is our responsibility to help not only the kids with arthritis
in our clinic but also the kids with arthritis in
What’s does this mean exactly? Spell it out. OK. I
believe that it starts with a cooperative, equal relationship between our
pediatric rheumatology leadership in councils and executive committees and in
the general membership of our multiple organizations. The pediatric
rheumatology leadership of ACR, the JPS (Japanese Pediatric Society ), the BSR
(British Society for Rheumatology), the AAP (American Academy of Pediatrics),
CPS (Canadian Pediatric Society), SPR (Society for Pediatric Research), CARRA,
EULAR, PRES, PRINTO, CPRA (Canadian Pediatric Rheumatology Association), ISR
(Italian Society for Rheumatology), APLAR, PANLAR, parent organizations, and
many other organizations should work to establish and maintain a level playing
field of mutual respect and cooperation without a pecking order. Beliefs and
behavior of elitism and superiority need to be minimized and rivalry between
the organizations and individuals made unacceptable. We need to build each
other up and verbally support each other. We need to follow these words of
support with actions of support, cooperation, and collaboration. Each of our
organizations has a niche, its own worth, and its place. Each has its own
potential to benefit patients and our field in general.
Does that mean
that I believe that there is some rivalry, competitiveness, elitism, and
pecking order in our field? We are no different than other fields of medicine.
I’ve observed that there are some zero-sum characteristics in our field. I
personally have been competitive all my life. Ask my family. Have I interacted
with peers in a zero-sum way? Absolutely. But I think that all of us can do
better in developing pediatric rheumatology if we embrace more
non-zero-sumness- cooperation and collaboration.
Within
organizations and countries, as well as internationally, we should avoid as
much as possible personal rivalries and animosity, and minimize the competition
between centers. We should also try to rid ourselves of attitudes focused on
who is best, who has the best treatment approach or most impressive CV, and who
is more important, and using non-zero-sumness, work for the common good of our
field and our kids.
Most importantly, we should focus on the work we can
do together to improve pediatric rheumatology all over the world over the next
few decades. As I have mentioned before, in any one country, we are a small
group, but internationally we are much stronger. So more than most other
pediatric subspecialties, it is crucial that we band together in a
collaborative group of professionals to advance our field.
I believe that we should also utilize equally both
adult and pediatric organizations. Many of us have identified ourselves as pediatric RHEUMATOLOGISTS where we may
feel more a rheumatologist than a pediatrician, relate more to rheumatologists
than pediatricians, and embrace the ACR, EULAR, Canadian Arthritis Network
(CAN), and other adult rheumatology organizations more than pediatric
organizations. Others, at times, may identify themselves more as a PEDIATRIC
rheumatologist where their relationships to pediatricians, pediatric
subspecialists, and pediatric organizations (e.g.
I would suggest that pediatric rheumatology needs all
these organizations to help us develop and provide good care for children with
rheumatic disease. We should endeavor to be PEDIATRIC
RHEUMATOLOGISTS, focusing on both our pediatric and rheumatology halves. We
can obtain much help and support from adult rheumatology groups and
organizations and we should utilize them to the fullest.
Yet, they will never provide all that we need. It is
unfortunate but, in my opinion, it is undeniable. Adult rheumatologists have
their agendas and pediatric rheumatology is often peripheral to their
interests. From my observations, internists as a group do not always consider
pediatricians to be their peers and our patients are as important as their
patients. Plus there is a built in competition for patients. Many adult
rheumatogists may feel that they can care for children in the second decade of
life, and even children in the first decade of life, as well as we do. Do they really believe in our niche?...many
do, but not all.
There is another possible inherent conflict of
interest. I believe that it is our job to build up pediatric rheumatology in
the next 50 years to the point that adult rheumatologists do not have to see
any children with rheumatic disease at all-that in every country there will be
sufficient pediatric rheumatologists. Could you imagine suggesting that
children with congenital heart disease or brain tumors can be adequately cared
for by adult cardiologists or neurosurgeons in the future? I doubt very
seriously that the leadership of adult rheumatology and the average
rheumatologist have these goals in their agenda or even would agree to them.
So, we can obtain help from the adult rheumatologists and their organizations,
but there are limits to that help.
Similarly, we can work within pediatric organizations
to advance our field and help our patients. After years of volunteering for the
International pediatric organizations may help us
develop our subspecialty around the world. Pediatric research organizations may
allow us to interact more with subspecialists and researchers who are not part
of the rheumatology universe. Working in these pediatric research groups may
allow us to appear more on the radar of pediatric departmental chairmen who
often may seem to undervalue pediatric rheumatology and not provide us with
sufficient help and resources.
Therefore, I believe that it is just as important for
us to join and participate in pediatric organizations as rheumatology
organizations. We need to join and work hard in PRES, AAP, PRINTO, Canadian
Pediatric Rheumatology Society (CPRS), SPR, and international pediatric
societies just as much as we join and work in the ACR, EULAR, PANLAR, and
APLAR. We should build up pediatric organizations for pediatric rheumatology
everywhere, particularly for research grants, basic research and clinical trial
collaborative groups, center funding, and philanthropy. We need to limit bias
and elitism as well, recognizing all the organizations and the work in each
organization as equal and praiseworthy. We should join both adult and pediatric focused organizations and support
them financially. We need all the help we get from both universes. Each can
give us something we can not get from the other.
So I would suggest to you that we have our work cut
out for us in developing pediatric rheumatology in the 21st century.
I would urge us to embrace Wright’s non-zero-sumness collaboration and
cooperation strategies and limit zero-sum competition as best we can. We need
to work hard within both adult and pediatric organizations, national and
organizational. In my opinion, this approach offers to us our best chance of
developing pediatric rheumatology, sooner rather than later, and helping the
millions of children with rheumatic disease in our own and other countries and
regions who still suffer from significant illness without pediatric
rheumatology expertise.
Charles
H. Spencer
Chicago