Utopia and modern medicineML Kothari, Lopa A Mehta
Department of Anatomy, Seth G. S. Medical College and K.L.M. Hospital, Parel, Bombay-400 012, India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 722610
Source of Support: None, Conflict of Interest: None
At a time when Nobel awards for Medicine chase only the molecular biologists, when the basic-science route is considered the way to medical nirvana ,,,, ,and when Presidents and politicians roll up their sleeves to conquer, say, cancer , at any cost, it is time to speculate on the shape of medical things to come, by the close of this century.
The air, in countries overdeveloped or otherwise, is of given-enough-dough-anything-can-be-achieved. Assuming the entire OPEC earnings were pipelined to medical research from today, what would Modern Medicine (MM) be in the 21st century? Let us consider the medical futurama in 3 parts: (a) where MM is right now; (b) why it is where it is; and (c) what would MM be, given 25 years and money for the asking! Diseases in our medical school days were conveniently classified as congenital and acquired, the latter comprising traumatic, infective, neoplastic, metabolic, degenerative, and psychic; the same classification can be used here.
"It is a sobering thought that after several decades of research, a number of international conferences and many other meetings, seminars and symposia, the problem of human malformations remains essentially unchanged." Having so introduced a symposium, McKeown  proceeds to chastise MM further on human malformations-etiology unknown, rate unchanged, relative contribution to infant mortality greatly increased. Trauma, MM can "treat," for God, a la Ambroise Pare, continues to heal the wound with the same pristine secrecy that a century's research  on would-healing has not scratched even on the surface. A few things are certain in life, and the rapid appearance of bacterial resistance to a newly introduced drug is one of them.  The latest bug to bug antibioticism is the penicillinophagic gonococcus, reported from St. Thomas's.London  Dubos  begins his chapter with disquieting heading-THE SOCALLED CONQUEST OF MICROBIAL DISEASES-pointing out that there has been no decline in the percentage of hospital beds occupied by patients with infections, as compared to 50 years ago. On the tumor front,  the outcome of untold manhours of research and uncountable moneys-now more people live on cancer than die of cancer  -has been "precisely nil, " the whole anticancer crusade having been declared as "scientifically bankrupt, therapeutically ineffective, and wasteful."  Diabetes mellitus, as a paradigm of metabolic disorders, continues to ail from definitionlessness and is comprehended the less and less the more and more we know about it. , Cardiovascular disorders have not decided where they etiologically belong and research on its leading members-myocardial infarction, hypertension, strokeoffers nothing special to write home about. ,,,,,, On the senescent front, rats kept in a "Rat Palace" senesce the same way as do rats in sewers, forcing the investigators to declare that degeneration and death are unalterably, and predictably, built into the rats, the rat-findings being comfortably extrapolatable to the human situation.  While hopes are raised that some wundermittel might prevent the decay of aging ,, Selye  concluded a gerontologic symposium on a totally pessimistic note. Finally coming to psychiatric disorders, one has only to see/read One Flew Over the Cuckoo's Nest, to realize where the psychiatrists and their patients are. ,, It may be that the foregoing forced Malleson  to write Need Your Doctor Be So Useless?, and Burne  to candidly declare that MM as an enterprise has virtually reached the stage of zero returns.
Why is MM where it is? The responsible factors operate both within MM, and without. The former include MM's causalism, experimentalism, compromisism and promisism. The latter comprise bioforces that are wholly outside MM's realm-individuality, herdity (herd-ity), and temporality.
Causalism-the kill-joy crusading that makes breakfast butterless/breadless/ sugarless/cyclamateless/coffeeless, and amorous bedtime fraught with cancer has not for once satisfied the basic tenet of causalism: the cause must be followed by the effect, and the effect preceded by the cause, without any temporal gap in between. Bertrand Russell  threw away causalism from "advanced science" long ago, but it seems to survive in MM, probably because MM is neither advanced nor scientific. A direct offshoot of causalism is preventionism which "contains more unknowns than scientific truths."  The unmitigated failure of MM on all major fronts is by itself a testimony to the failure of MM's experimentalism. In cancerology, for example, experimentalism has not provided one causative/curative cue that was not known before the experiments were started. , A learned book  purporting to solve AM's problems has a recurring refrain-"the absence of a suitable (animal) model"; yet having admitted so, it goes on to describe one experiment after another, in one section after another. The force that keeps MM's experimentalism alive and kicking has been aptly summed up by Burnet:  "I believe however, that one might justly summarize American medicine as being based on the maxim that what can cure a disease condition in a mouse or a dog can, with the right expenditure of money, effort and intelligence, be applied to human medicine." MM's compromisism. consists in its being unable to define essential hypertension, diabetes mellitus, cancer, immunity, tumour immunity, and so on, and yet spawn on each one of these a burgeoning science-each oversized, amorphous and labyrinthine, with ramifications that have neoplastic autonomy, draining away resources in "a remorseless but seemingly purposeless growth. " MM is more political ,,, than potent, and hence promisism is its only way of survival. That is how cancer is cured every week,  and prophylaxis and cure of diseases are promised via genetic engineering  that also forms the title of a new MM journal. 
The more important thwarters of MM are too far from its curative reach, too abstract to be attacked by OPEC opulence. Every human being is governed by the bioforces of individuality, herdity, and temporality-biolaws that can be understood, not altered. Individuality implies, in Dubosian  phraseology, unprecedentedness, unparalleledness and unrepeatability, an unsituation from which even homozygous twins are not exempt. Herdity means that every feature-anatomic, physiologic, pathologic-of an organism is a part of the whole herd, enjoying its own place somewhere on the curve of normal distribution and falsely designated hyper-, eu-, or hypo- by the medical men suffering from diagnosophilia. Temporality or chronicity (chronos, time) is a bit difficult to appreciate, but Portmann  makes it lucid: "Animal life is configured time."
Individuality rules out our breaking the transplant barrier, even among the inbred animals. No two individuals throughout the history of mankind would have the same "immune" genotype for the individualistic repertoire of DNA is endless-"the figure 256 followed by 2.4 billion zeros."  Despite "successful" renal transplants  now running into thousands, the problems, , that plague the procedure remain unabated. Immunosuppressors promote graft-survival -at what overall cost, we do not know -but MM has no means , of altering the self-ishness of a single human being, a situation that makes transplant, a hit-and-miss measure for all time to come.
An individual's biotrajectory is an unpredictable element  ruling out modern medicine's ability to predict who will get what disease, when, and to what end. Screening programmes will thus always remain a travesty of medical common sense; prognostic judgments shall betray the judge now and again; therapy by rule of the thumb (and so it will always be because of an individual's unpredictability) will boomerang often to prove costlier than the disease. Many a patient, with diabetes far more severe than that of his physician who strives to be fit as a fiddle, will outlive the latter, a thing equally true of heart disease, hypertension or cancer. Physician, better kneel before the nemesis of thy perennial ignorance!
Herdity is the least understood aspect of biology: It is, to use a Galtonian phrase, "the supreme law of unreason" that governs the distribution of all phenomena in a herd, thus dictating that someone with carcinomatous stomach dies at 19 and someone at 91, or that someone's serum cholesterol level should be on the "higher" side because someone else has it on the "lower" side, both being normal. The medico is merely nursing an illusion when he relates the "levels" to heart attacks or hypertension. Willis,  the tumour pathologist, has alluded to "the smooth ideal curve of the age distribution of a large series" of cancers in general. What is normal, MM seems to forget, is the frequency distribution, that shows itself as the typical bell-shaped Gaussian curve serenely ruling over such mundane things as ocular refraction,  red cell diameter,  and the effect of pH/temperature on enzyme activity,  as well as such anxiety-making things as blood pressure  serum cholesterol,  IQ,  age-incidence at diagnosis of/death from gastric ulcer,  duodenal ulcer,"' carcinoma stomach  in men and women. The tails of the normal Gaussian curve stretch to infinity,  a thing that explains carcinoma tongue in a new born, or a disease-free individual aged 105 years. Summarizing, one may define herdity as a force that governs the ages, levels and so on, in a herd, the herd controlling the individual and vice versa. "Population thinking denies uniformity and looks to the range of diverse individuals within a group. The range, not the average, is the reality." 
If, a la Portmann,  man is configured time, then man as being time-bound, is unhelpably and unarrestably prone to disfigurement on passage of time. Cancer is not a disease, but a programmed event, strictly obeying the temporal programme within an individual, in consonance with the herd. "Senescence takes a generally similar form in each species, whether judged by the physicochemical changes in collagen, the incidence of degenerative changes in blood vessels or the high incidence of malignant disease .... The essence surely is that there is a genetic `programme in time' laid down for each species. There must be a biological clock and a means by which a series of processes can be made to occur according to the expediencies of evolutionary survival." This timely statement by Burnet  on human/animal survival and senescence sums up the truth about herd mortality governed by time. The appellation chronic is most appropriate for all forms of degeneration ranging from a symptomless cervical spondylosis to a rapidly lethal cervical carcinoma, since both the processes are temporal, or chronic. It is not this gene or that, that mediates the occurrence of heart attack or cancer. It is the time-order that the genes follow in harmony with the herd and in conformity with the individual's programme.
What would, or should, MM be by 2000 AD? By then, it may have freed itself of the anthropocentric do-goodistic cocoon, to view life, disease and death from a wider, biological, perspective. Hopefully, then, MM would be more aware of the ignorance it is steeped in and the uncertainties it faces. When this is made public, more doctors and more patients will abjure "exaggerated opinion of the powers of medicine," a relevant warning-phrase that Jacob Bigelow  uttered in the earlier half of the 19th century. "Medicine, like women's shoes, is governed by the dictates of fashion." Having said this, Humphries  suggests that the fashion ought to turn in the direction of economy rather than into that of waste and pollution. If Humphries is heeded to, the Everest Complex- "because it is there" -would no longer dominate medical research, although this is a moot point on which, to cite an example, two top men , from the same leading institute hold polar-opposite views. MM
Thanatorealism-that death has its own rightful reasons for being around-is gradually dawning upon lay and medical minds. ,,, To this robust approach to death, MM may add a robust approach to life by emphasizing a la Thomas , the built-in durability and sheer power of the human organism, instead of portraying it-as is the raging fashion now-as a teetering, fallible contraption always in need of watching and doctoring. Life may not be demedicalized to the Illichian extreme, but surely, all that is unnecessary-9/10th of what is prescribed -could easily be done away with, by 2000 kD.