Abstract: One of the most fascinating subjects in human history is the endless effort to cure the sick and heal the wounded. Since humans first walked the earth, they have sought to prolong life - beginning with prayer and magic, then with natural remedies discovered by accident, later with increasingly scientific modern medicine and now with minimally invasive surgery, organ transplantation and gene therapy.

However, opposing forces are pulling the medical profession in different directions. The physician is asked to spend more time with the patient and maintain higher standards of practice yet at the same time the physician is increasingly cast as a provider of health care, scrutinized, audited and regulated by agencies and paid by discount and capitation.

While we have clearly made leaps and bounds in medicine in the last decade, significant threats on the horizon could compromise medical progress and the future quality of medical care. We must continue to support basic and applied biological science, clinical investigation, specialty research and development and specialist medical education, for these efforts will continue to enhance dramatically the ability of physicians to prevent, diagnose and treat disease. Many of these advances will continue to markedly reduce the cost of health care.

In surveying the state of medicine today, one is impressed by the contrast with earlier centuries. For the first 30 years of the twentieth century, viruses could be studies only by their pathogenic effect on animals they infected. The proof that a malignancy was present has rested on the microscopic characteristics of a piece of tissue since the 10^th century. However, other general diagnostic methods developed since have increased the chance of detecting cancer. Although blood transfusions are know to have been performed as early as the 17^th century, nearly all early blood transfusions resulted in death of the recipient to the point that the government in Rome outlawed the transfusion of blood in the 1660"s. It wasn't until 1908 that Ottenberg tested the blood of the donor and recipient before every transfusion and safe blood transfusions opened the way for surgical procedures otherwise too dangerous. Fractures of the hip were long considered untreatable and until the present century little was done for them. A bold concept that was almost entirely the product of the 20^th century was the removal of a diseased organ and the transplantation of a healthy organ from another person. The first bonafide report of organ transplantation came from Vienna at the turn of the 20^th century. Diseases like smallpox, cholera, and diphtheria which devastated populations as late as the 19^th century are now rare in most parts of the world, many formerly hopeless diseases are readily curable with medication, the surgeons techniques have advanced to major surgery with only small laparoscopic scars, and irreversibly diseased organs are replaced by grafts and transplants or by mechanical devices.

The 1980's brought the first artificial intelligence program for medical diagnostic usage, MYCIN, designed to assist with managing drug interactions with antibiotics; various tumor markers for specific cancers were identified; and oncogenes were discovered by R. Weinberg and M. Barbacid. The Jarvik-7 artificial heart was inserted in Barney Clark, and a natural hormone, tissue plasminogen activator (TPA) was made available for treatment of heart disease and stroke. Genetically engineered drugs were developed.

A newer body scanner, especially for soft tissues, Magnetic Resonance Imaging (MRI), became available as did Magnetic Resonance Spectroscopy (MRS) for analysis of body chemistry. Similarly, MRI cine-imaging was developed to show the motion of the heart.

While truly remarkable progress has been made over the last century, the pace of progress and range of accomplishments in medicine in the last decade dwarfs all previous major advances throughout history. At no time in the past century have so many advances been made that have revolutionized patient care in areas such as measles, myopia, Parkinson's disease, prostatic hypertrophy, cystic fibrosis, respiratory distress syndrome, melanoma, Gaucher's disease, spinal cord injury, angina, many types of cancer, muscular dystrophy, and burn injuries, only a few of the many areas of medicine in which new curative, preventative, palliative, or therapeutic approaches have been developed in the last few years.

For example, in 1984, the first baby was born from a donated embryo; the transfer of the embryo differed from test tube fertilization and involved no surgery. American and French researchers, working separately, reported that they had identified viruses that appeared to be the cause of AIDS. The heart of a baboon was transplanted into a 15 day old girl who lived less than 3 weeks after the transplant. In 1985, surgeons began to use lasers for a wide variety of surgical procedures which revolutionized surgical treatment. U.S. scientists discovered the first gene known to inhibit growth. British surgeons in 1986 performed the world's first triple transplant (heart, lung, and liver). In 1987, the U.S. government approved the use of AZT to combat AIDS. U.S. surgeons in 1988 implanted the world's first plutonium powered pacemaker. In 1988, Surgeon General C. Everett Koop issued a report declaring that cigarettes and other tobacco products were addictive. Later in 1989 Surgeon General Koop released a report that lung cancer was the leading cause of cancer death among women. In 1990, the Nobel Prize for Physiology and Medicine went to Joseph E. Murray who performed the first kidney transplant and E. Donnall Thomas who first transplanted bone marrow between humans. In 1990, a four year old girl became the first human to receive gene therapy. Other technological advances amaze the world of medicine in the 1990's. Ultrasound scanners can produce two-dimensional slice information at high speed, tracking moving structures in the body. They have been miniaturized to one millimeter for use with endoscopes and other surgical instruments. Doppler scanning provides information on rates of blood flow never before available. Magnetic resonance imaging is becoming less expensive and artificial intelligence is making significant advances. Small satellite dishes and other equipment make telemedicine available at remote sites. Continuing enhancements of the Internet, with sophisticated web browsers, provide access to medical information worldwide. In 1995, Robert Lefkowitz of Duke University with Gabriele Ronnett and Loren Wallensky of Johns Hopkins University announced that molecules used by the nose to detect scent had been found on sperm, suggesting a microscopic courtship as sperm follow the perfume of human eggs. Molecular biologists at the University of Texas at Austin are exploring the role of Darwinian evolution in medicine, particularly in regard to the overuse of antibiotics in causing resistance to tuberculosis. The University of Texas School of Public Health at Houston and M.D. Anderson Cancer Center in Houston are studying alternative medicine - including evaluation of herbal and biopharmaceuticals espoused by some for cancer treatment. Studies are being reported on psychoneuroimmunology and its relation to disease.

In the last few years we have entered the age of super tests where diagnoses are made with nuclear magnetic imaging, positron emisson tomography, evoked potentials, and mapping of the brain. Childbirth has entered a new era with invitro fertilization, embryo transfer, surrogate mothers, sex selection, cloning, and fetal surgery. Surgical techniques are minimally invasive and laparoscopic. A laser's beam has been turned against many disease including cataracts, dermatologic disease, blocked arteries, endometriosis, enlarged prostates, and cancer. We've entered the world of genetic medicine with gene mapping, DNA probes, prenatal screening, gene therapy, genetically engineered natural drugs and vaccines, and genetic screening in the workplace. Mapping of the human genome with its 100,000 genes, the isolation of the expected 50,000 gene products by which genes carry out their functions, and elucidation of how these genes and products might be used for therapy are but a few goals of the Human Genome Project. The Human Genome Project is a 15 year project with several institutions working to elucidate the complete genetic blueprint of humans and several other organisms. The goal is to identify the precise sequence of each of the 3 billion bases in human DNA Currently, about 1% of the total number have been sequenced. A complete understanding of the human genetic blueprint will allow physicians to more efficiently identify genes associated with thousands of diseases. In the future, therapeutics for some genetic disorders will be based on presymptomatic knowledge of an inherited condition and might take the form of lifestyle changes, increased surveillance and targeted intervention. The ability to define precise molecular defects causing disease has led to introduction of the normal form of gene into an affected patient i.e., gene therapy. Although the extent of success of gene therapy is controversial, at least two chromosomes have been completely mapped and no less than 25 protocols for gene therapy have been implemented and/or approved. At least 50 disease causing genes have been identified. Among the discoveries is the genetically coded protein apolipoprotein-E4, known as APO-E4, the Alzheimer's gene. The discovery has fostered basic research in other brain diseases and head injuries.

The implication of this revolution for the future, including future diagnosis, prevention, and management of disease, cannot be overemphasized. Neither can the economic implications. Clearly, not only the effects on our health but the products, devices, processes and procedures that are emerging from research laboratories have enormous economic impact. The vast sector led by the National Institute of Health, National Science Foundation and privately endowed efforts are promoting research in academic health center, training scientists and spawning Nobel laureates. Major efforts have also been made by pharmaceutical companies and the biotechnology industry. Together, these groups have invested more than $30 billion per year in research and development, contributing not only to medicine but to the economic growth of the U.S. More than 70 biotechnology companies are working on AIDS treatments, about 25 companies on Alzheimer's disease, another 50 on other diseases of aging such as Parkinson's disease, arthritis, and stroke. In addition, 60 biotechnology companies are working on treatments for medical conditions primarily affecting women, such as breast and ovarian cancer, osteoporosis, depression and multiple sclerosis. The biotechnology industry has already invested at least $10 billion to develop the advanced molecular biological techniques that offer new tools for understanding the mechanisms of human disease and for precisely designing therapies that complement natural immunologic properties. These developments will provide not only important therapeutic benefits to patients but will also help contain health care costs in the future. Diseases result not only in direct cost of medical care but also have an enormous impact on disability, loss of productive work time, and premature mortality that result in major costs to the economy. Osteoporosis, diabetes, depression, arthritis, Alzheimer's disease, cardiovascular disease, and cancer alone are estimated to have cost the United State $379 billion in 1992.

While we have clearly made leaps and bounds in the last decade and opportunities in the next few years are endless, significant threats on the horizon could compromise medical progress, the future quality of medical care and the health and productivity of our nation. We are in a new economic and political climate fraught with reduced federal funding for science and research and ideological battles in many areas. Many of those pressuring for cost containment have not recognized the complex forces that have shaped the U.S. healthcare system including biotechnology, specialty research and development, clinical investigation and specialist medical education. Failure to understand and protect these assets could result in a sharp decline in the quality of medical care provided to patients in the United States. We must continue to support the advances in basic and applied biological science that have occurred at an unprecedented rate in the last few years. These advances will continue to enhance dramatically the ability of physicians to prevent, diagnose, and treat illness and many of these advances have and will continue to markedly reduce the cost of health care, despite an initial investment of funding.

In summary, the tremendous progress we have seen in the last decade in healthcare has enabled us to prolong life, increase the quality of life and enjoy life in ways enabled by better health. As those of us in this generation ponder the challenges currently facing the healtcare system, will the trend to prolong life and increase the quality of life through better, more specialized ways of preventing, diagnosing and treating disease continue or will we regress to maintaining status quo or less. Each of us, in both the lay and medical communities, will have a part in making this decision about the future of our most valuable possession - our health.

BIBLIOGRAPHY

1. Lyons, Albert S. M.D. and R. Joseph Petrucelli II, M.D. Medicine: An Illustrated History. New York: Abradale Pres, 1987.
2. Omni's Future Medical Almanac. New York: McGraw Hill Book Company, 1987.
3. Scientific American Science and Medicine, Nov/Dec 1995.
4. The Timetables of History, new Third Revised Edition.

editor@medmag.org