Shooting for the Moon or Flying Too Near the Sun? Crossing the Value Rubicon in Precision Cancer Care

In his last two State of the Union addresses, President Barack Obama has focused on the need to deliver innovative solutions to improve human health, through the Precision Medicine Initiative in 2015 and the recently announced Cancer Moonshot in 2016. Precision cancer care has delivered clear patient benefit, but even for high-impact medicines such as imatinib mesylate (Glivec) in chronic myeloid leukaemia, the excitement at the success of this practice-changing clinical intervention has been somewhat tempered by the escalating price of this 'poster child' for precision cancer medicine (PCM). Recent studies on the costs of cancer drugs have revealed significant price differentials, which are a major causative factor behind disparities in the access to new generations of immunological and molecularly targeted agents. In this perspective, we will discuss the benefits of PCM to modern cancer control, but also emphasise how increasing costs are rendering the current approaches to integrating the paradigm of PCM unsustainable. Despite the ever increasing pressure on cancer and health care budgets, innovation will and must continue. Value-based frameworks offer one of the most rational approaches for policymakers committed to improving cancer outcomes through a public health approach.

Liberty and individuality: the colony asylum in Scotland and England

This paper analyses the buildings, spaces and interiors of Bangour Village public asylum for the insane, near Edinburgh, and compares these with an English asylum, Whalley, near Preston, of similar early-twentieth-century date. The village asylum, which developed from a European tradition of rendering the poor productive through ‘colonisation’, was more enthusiastically and completely adopted in Scotland than in England, perhaps due to differences in asylum culture within the two jurisdictions. ‘Liberty’ and ‘individuality’, in particular, were highly valued within Scottish asylum discourses, arguably shaping material provision for the insane poor from the scale of the buildings to the quality of the furnishings. The English example shows, by contrast, a greater concern with security and hygiene. These two differing interpretations show a degree of flexibility within the internationalized asylum model which is seldom recognized in the literature.