On the Science and Technology of Medicine

October 11, 2009

Lewis Thomas revisited:
In honour of the Golden Anniversary of the Gairdner Foundation

Good evening, ladies and gentlemen.

This golden anniversary gala reflects the vision of James Gairdner and his family’s loyalty to that vision. It reflects the dedicated service of volunteers who have helped to guide and support the Gairdner Foundation and choose the winners. And it also reflects the leadership and tireless efforts of the individual who has led the Foundation so successfully since 1993 — Dr John Dirks.

On behalf of Canada’s universities I am delighted to thank the many Gairdner laureates from years gone by who have joined us for these celebrations, and to extend warm congratulations to this year’s winners. Your collective achievements have had an immeasurable impact on the lives of hundreds of millions of people all over the world.

I also want to acknowledge our national government for providing a $20M endowment two years ago to sustain the Gairdner Foundation in its great work. In so doing, Prime Minister Harper made an important statement to Canadians and the world: We are not afraid to recognize the best, compete with the best, and, in the Canadian tradition, collaborate with the best. In that respect, tonight’s audience arguably represents the most extraordinary gathering of world-class minds that Canada has seen since the founding of this nation 142 years ago.

Speaking for universities, I am mindful of the adage of a predecessor of mine, namely, that ‘A University president must be a ball of fire by day and a bag of wind by night’! I shall try not to be too windy tonight. Instead, I want to undertake a short expedition in the realm of intellectual archeology. More specifically, I want to reflect very briefly on the mission of the Gairdner Foundation by revisiting a classic paper by Lewis Thomas. For 20th century medicine and medical research, Lewis Thomas was a magisterial and multi-dimensional figure analogous to Sir William Osler in the 19th century. Thomas’s four score years spanned a period in which, as he was fond of saying, medicine went from being the oldest art to the youngest science. So it was that, in an essay published in 1977, Thomas tracked the progress and impact of science and technology on clinical care and public health. It was and remains a sobering assessment.

Dr Thomas argued that, for the vast majority of major diseases, the available interventions were far from definitive. He characterized these measures as halfway technologies – often expensive, sometimes risky, and not particularly effective. He urged not only a critical assessment of those halfway technologies, but societal patience and ongoing investment in science. Wise words, I think, but what would the verdict be today, updating that assessment some three decades later?

First, we have made substantial progress. Age-adjusted death rates from most of the major scourges are falling in the industrialized and industrializing countries. Billions of people are living longer and better, albeit often living with and suffering from one or more chronic diseases. To be sure, improvements in population health status are not new. However, in much of the nineteenth century and, arguably, the first half of the last century, such trends were overwhelmingly attributable to changes in society and sanitation that took place outside the healthcare system.

Recent progress, in contrast, is due in major measure to the more effective prevention and management of a vast range of diseases. And that progress, in turn, has its foundations in a combination of fundamental and translational bioscience, clinical and epidemiological research, and advances in the organization and delivery of healthcare. I should add that a roll-call of those advances would bring to the fore very quickly the roughly 300 Gairdner laureates of the last fifty years, not least all those laureates gathered here this evening.

What are some examples of these changes?

Well, in the mid 1970s Thomas wrote: “…in general, cardiovascular disease lacks any decisive, conclusive technology with the power to turn off, reverse, or prevent disease.” He added that a “direct approach to coronary disease must await the future.” Thomas would have been surprised at just how quickly the future arrived in prevention and care of patients with vascular diseases.

We now fiddle brilliantly with blocked or narrowed arteries, and the standard cocktail of medications prescribed after an acute myocardial infarction reduces medium-term mortality by up to 80%. Then again, we do not really have a definitive intervention to prevent let alone rapidly reverse atherosclerosis. And while we can prevent strokes in many patients, for millions of young and old persons alike, brain tissue death remains a debilitating and permanent event.

In cancer control, we have made huge strides. The linkage of human papillomavirus to cervical cancer and the development of the HPV vaccine is one such advance that is rightfully front and centre tonight. But again, let us be candid: The toll of cancer remains massive, and it will be decades before we have definitive treatments for this baffling and protean family of proliferative disorders.

And so it is more generally with modern medicine – everywhere a mixture of great successes and continuing challenges.

In 1977, the world had essentially eradicated smallpox, but today, we still struggle with the massive toll of diseases related to tobacco addiction. Then, with apologies to Dickens, there is ‘a tale of two arthritides’. When Lewis Thomas wrote his chastening essay, the role of short-range messengers such as cytokines was just coming into focus. No one could have imagined the importance of antibodies to tumor necrosis factor in relieving symptoms and arresting joint destruction in rheumatoid arthritis. It is wonderful to think that the next generation of health professionals may never see those characteristic deformities in the hands of a patient with longstanding rheumatoid arthritis. In contrast, however, osteoarthritis remains a disease that many associate with the phrase ‘wear and tear’, as if we were pieces of furniture rather than living, regenerating organisms. And despite advances in our understanding of articular cartilage and the widespread use of arthroscopy, I would submit that the treatment of osteoarthritis has advanced little in the last three decades.

Finally, lest there be any doubts about our ongoing challenges, emerging and re-emerging infectious diseases have taken a massive toll worldwide in the last thirty years. Indeed, while Lewis Thomas was writing, HIV was still in its quiet phase, but in a few short years, had spread across five continents. My conclusion, by now, will be obvious. We don’t know enough.

It is true that we must relentlessly and rigorously synthesize, critique, validate, and apply the evidence that we already have.

It is true that public health strategies and health care have never had more to offer than they do today. And so we must be attentive to the equitable and efficient organization and delivery of measures to improve the health of individuals and populations.

It is also true that we must do more to address what Geoffrey Rose called “the causes of the causes”.

Some two billion people worldwide still suffer because of dirty water, malnutrition, substandard housing, and oppressive political circumstances. In the year that the Gairdner Foundation has given its first ever Global Health award, let us rededicate ourselves to mitigating these shameful health disparities.

We know, however, what comes next as populations move out of the shadow of the diseases of poverty. They fall prey to the chronic diseases endemic to members of this audience. And as that happens, the quest to conquer chronic diseases, and the marshalling of global forces to counter emerging and re-emerging infectious diseases will become, more than ever, a great unifying preoccupation for humankind.

In the decades ahead, I have no doubt that Gairdner prize-winners will continue to be at the forefront of that noble collective enterprise. Their discoveries in basic science will have far-reaching and entirely unpredictable impacts. And their work in translational, clinical and epidemiological research will ultimately change the face of public health and professional practice.

In closing, then, thank you to the Gairdner family and Foundation for your continuing dedication to excellence. And thank you, most especially, to the laureates for all that you have done and continue to do for the advancement of science and the betterment of the human condition.

Acknowledgment: This speech is based on a paper in preparation, coauthored by Irfan Dhalla, Department of Medicine, St. Michael’s Hospital and the University of Toronto.