NIH Is `Century's Finest Social Invention'

Editor's Note: In his latest book, The Fragile Species (New York, Charles Scribner's Sons, 1992), scientist-author Lewis Thomas offers a collection of 14 essays, covering a wide range of personal, social, and scientific issues. Prominent among these is the relationship of basic scientific research, the achievements of modern medicine, and the future promise of an ever-healthier population. However, Thomas--who is president, emeritus, of the Memorial Sloan-Kettering Cancer Center in New York and the author of such best-selling books as The Lives of a Cell (New York, Viking Press, 1974) and The Medusa and the Snail (Viking, 1979)-- points out that, for steady advances in medicine to be achieved, basic research in biomedical science must have the government's robust support. In the following excerpt, Thomas argues eloquently on behalf of a strong National Institutes of Health, stressing that the funding agency must operate unencumbered by outside interference. My contention is that we do indeed have some science in the practice of medicine, but not anything like enough, and we have a great distance to go. Indeed, most of what is regarded as high science in medicine is actually a set of technologies for diagnostic precision--the CAT scan, NMR, and many exquisite refinements of our methods for detecting biochemical abnormalities of one sort or another. But these have not yet been matched by any comparable transformations in therapy. We are still confronted by the chronic disablements of an aging population, lacking any clear understanding of the mechanisms of these diseases--dementia, for instance, or diabetes or cirrhosis or arthritis or stroke and all the rest on a long list--and without knowing the underlying mechanisms we lack new therapeutic approaches. To be sure, we do have some spectacular surgical achievements in the headlines--the transplantation of hearts, kidneys, livers, and the like--but these are what I have called halfway technologies, brought in to shore things up after the still- unexplained diseases of these organs have run their course. And these measures, plus the new advances in diagnostic precision, account for a large part of the escalating costs of health care today. It seems obvious, to me anyway, that the only practical policy for bringing down those costs will be by more and more basic research in biomedical science, in the hope and expectation that we can then begin to understand, at a deep level, the underlying events in human disease. Sooner or later I am confident that this will be accomplished, and I hope for the sooner. This is the mission, by the way, of the National Institutes of Health, and I hope nobody tries to disturb, for any political purpose, the functioning of this extraordinary institution, either by "privatizing" it, as some ideologues have openly proposed, or by micromanaging its affairs, as congressional committees are sometimes tempted to do. I have thought many times in recent years that if you are looking around for some piece of solid evidence that government really can work brilliantly well--and these days many are indeed looking despairingly for such evidence--take a glance at NIH, in its singular way the finest social invention of the twentieth century. One reason why medical history is not much taught in medical schools is that so much of it is an embarrassment. During all the millennia of medicine's existence as a profession, all the way back to its origins in shamanism, public expectations have been high, demanding, and difficult to meet. First among the demands was to recognize the existence of a disease, explain it, and then make it go away. For most of its history, medicine has been unable to do any of these things, and its sole advantage to a patient seeking help lay in the doctor's capacity to provide reassurance and then to stand by while the illness, whatever, ran its course. The doctor's real role during all those centuries was more like that of a professional friend, someone at the bedside, standing by. When he was called a therapist, it was more in the etymological sense of the original Greek therapon: Patroclus was therapon to Achilles, part servant, part friend; he stood by him in his troubles, listened to his complaints, advised him when he could, put up with him, finally even died for him. Therapy was a much more powerful word for the ancient Greeks than it is today, and somewhere along the line it was picked up by the doctors. In its ancient meaning, it carries inside all the obligations that medicine and the other health professions have for patients with AIDS: to stand by, to do whatever can be done, to comfort, and to run all the risks that doctors have always run in times of plague. When I arrived at Harvard Medical School in 1933, nobody talked about therapeutics as though it were a coherent medical discipline, in the sense that pharmacology is today. To be sure, there were a few things to learn about: digitalis for heart failure, insulin, liver extract for pernicious anemia, vitamin B for pellagra, a few others. By and large, we were instructed not to meddle. Our task was to learn all that was known about the natural history of disease so that we could make an accurate diagnosis, and a reasonably probabilistic prognosis. That done, our function as doctors would be to enlist the best possible nursing care, explain matters to the patient and family, and to stand by. Moreover, we were taught that this was not only the very best kind of medicine--not to meddle--it was the way medicine would be for the rest of our lives. None of us, certainly not any of the medical students, had the faintest notion that our profession would ever be any different from what it was in the 1930s. We were totally unprepared for the upheaval that came with the sulfonamides, and then with penicillin. We could hardly believe our eyes on seeing that bacteria could be killed off without at the same time killing the patient. It was not just an amazement; it was a revolution. That made two revolutions. The first, that the medical treatments in common use for all the centuries before our time didn't really work, did more harm than good, and had to be given up, left us with almost nothing to do to alter the course or outcome of a human illness. And then the second, that a form of treatment based on fundamental research, tested in experimental animals, then tested in controlled experiments in human beings, was possible. Medicine, it seemed, was off and running. Nothing seemed beyond reach. If we could cure streptococcal septicemia, epidemic meningitis, subacute bacterial endocarditis, tuberculosis, tertiary syphilis, typhoid fever, even typhus fever, was there anything we could not do? Easy one hand, we thought. By the 1950s it was beginning to become clear that solving all the rest of medicine's problems was going to be a lot harder than we had thought. Some of us had overlooked the fact that the conquest of bacterial infection and the success in immunizing against certain viral diseases had not simply fallen into the lap of medicine. These things could not have happened at all without the most penetrating insight into the underlying mechanisms of the diseases we were able to treat or prevent so effectively. Not to say that we had much comprehension of how a meningococcus goes about producing meningitis, or how a pneumococcus does its special work in the human lung. These were blank mysteries, and to some extent the mechanisms of pathogenesis remain mysteries today. But what we did know were bits of crucial information: the names and shapes and some of the metabolic habits of the microorganisms involved, the specific pathologic changes they produced in human tissues, and the ways in which they spread through human communities. This information had not dropped into our laps. It came as the outcome of decades of what we would be calling basic biological science if it were going on today. Without the research in microbiology and immunology done in those decades, we would never have entered that first period of modern therapeutic medicine. Now things are beginning to change. A problem like cancer, which seemed simply unapproachable in the early 1970s, too profound even to make good guesses about, has turned suddenly into the liveliest, most exciting and competitive, and among the most allusive puzzles in all of biology. Instead of appearing to be one hundred different diseases, each requiring eventually its own individual solution, it now seems more likely that a single, centrally placed genetic anomaly will be found as the cause of all human cancers. The new information, coming in as cascades of surprise from laboratories all round the world, will almost surely lead to novel therapeutic and preventive approaches that cannot be predicted at the present time. There is something of the same excitement and anticipation within the rapidly expanding community of neurobiologists, keeping in the same close touch with each other across all international boundaries. The brain has been transformed within just the past few years from a computerlike instrument of unimaginable complexity to a system governed by chemical messages and run by the specific receptors of scores, more likely hundreds, of short peptide chains of command. Much of what is now happening in both cancer and brain research is the outcome of basic research that had neither of these problems in mind when the work was started, even when the definitive aspects of the work were well under way. The new field of molecular genetics began to catch glimpses of its potential when the restriction enzymes were discovered, and once the technology of recombinant DNA had evolved to the point where specific molecular probes were at hand, it became clear that the most powerful methods for studying the deep functions of cancer cells were also at hand. Meanwhile, the new technique of cell fusion had led to the development of hybridomas, and monoclonal antibodies had become indispensable for the study of gene products and cell surface antigens. But the people whose work made these techniques possible were not, at the outset of their work, aware that they were putting together a totally new set of approaches to the cancer problem. Early on, nobody engaged in the work could have predicted how it would turn out or where it would lead, nor can they predict the future benefits today, only that the work is engrossing and fascinating, and filled with surprises yet to come. This is the way it will go for the rest of medicine, if fundamental biomedical research continues at its present pace and scope. The dementias of the aged, coronary artery disease, arthritis, stroke, schizophrenia and the manic-depressive psychoses, chronic nephritis, cirrhosis, pulmonary fibrosis, multiple sclero- sis--any disease you care to name--will be opened up for closer scrutiny by discoveries still unpredictable in biology itself. The information needed for the future cannot be planned by committees or commissions, and there is no way for bureaucracies to decide which pieces of information are needed first, or at what time. In basic science the shots can never be called in advance--or by definition the enterprise is not basic science.

NIH Is `Century's Finest Social Invention'

Interested in reading more?

Become a Member of