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Thursday, October 22, 2009

Powerful tools out of control

I read an interesting book, "Demons under the microscope". It was a fascinating story about the origins of modern medicine, focusing on the the development of the modern pharmaceutical industry. Based upon the narrative of this book, the transforming event of modern medicine was the development of sulfonamide antibiotics in the early 1930's. Prior to the avialbility of this medication, physicians were uniformly therapeutic nihilists, and for good reason. Surgery, despite antiseptic methods was frequently complicated by life threatening and life ending infections. Childbirth was extremely dicey and frightfully large numbers of otherwise healthy women died from post-partum infections.

The introduction of sulfonamides changed more than therapeutics. Its introduction changed how people viewed medicine and how medicine viewed itself. The public's view of medicine changed to virtual awe. From expectations that included frequent and unexpected death from infection, the public moved to viewing physicians and modern medicine as regular miracle workers. However, that awe is now waning with an new generation whose perspective is that old miracles are now mudane expectations.

The boundless confidence of medicine post sulfa stands in marked contrast to the pessimism that marked medical therapeutics even months prior to the discovery of sulfa drugs. We tend to forget the extraordinary explosion of novel small molecule therapetics that followed sulfa development was preceeded by many decades of failed discovery, looking for magic bullets. The small molecule therapeutic explosion initiated by sulfa drugs unleashed not only a revolution in the control of infections, but also served as the impetus for development of coutless diagnostic and therapeutic interventions.

The tools that developed subsequently were simply unbeleivable. The chemical libraries with sulfa backbones were deployed to address other therapeutic targets such as hypertension and diabetes. Te ability to treat a host of primary and secondary conditions facilitated the drive to develop new diagnostic and surgical tools. The medical industry developed more and more powerful tools, much like the aircarft industry developed more and more powerful engines. Both of these industries strived to break through various barriers.

Successfully strapping a bizzilion horsepower engine onto an aircriaft ultimately required the simulataneous development of sophisticated control mechanisms. That much cannot be said for the health care industry. We have amazingly powerful tools which can be deployed in a host of ways but they are frequently deployed with either no control mechanisms associated or no one at the controls. That might not be a huge problem when those tools propel you at the speed of a gentle stroll. However, we increasingly find ourselves strapping therapeutic rockets to our patient's backs, excited that we can use them to gain altitude, without much forethought about where they will go and how they will land.

We can no longer live off the legacy of those pioneers who developed the first miracle drugs. Those miracles are simply what is expected as the norm. More powerful tools are great but the proliferation of options and the explosion of the diagnostic and therapeutic matrices make the development of control mechanisms essential for the next health care revolution.

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