Welcome to the future?

Our friend Blake, at Critical Condition, discusses NIH director Elias Zerhouni's interview in Health Affairs. I have a somewhat mixed view of Zerhouni's vision. He sees, quite correctly in my view, that we are at a major inflection point in the progress of biological science. An avalanche of revelations about biology on the smallest scale, the discovery and elucidation of the fundamental chemical machine parts of life, coincides with exponential expansion of our ability to manage and extract meaning from huge amounts of information. The promise is that we will be able to move beyond the reductionist view of the organism, of disease, and of therapy which dominates medical practice and biomedical research, to a holistic understanding of the human body and ultimately, an ability to stop disease processes before they start.

All of this may well be true. Science really does march on and it is possible that there will one day be a technical fix to the current crisis of our health care non-system. We cannot possibly keep spending ever more and more on trying to control chronic diseases that we cannot cure, by crude interventions that interrupt some part of the disease process while disrupting other essential life processes, leading to secondary effects that we then have to treat with other blunderbuss techniques. Some day, if the neocons don't start World War III and set us back to 1300 AD, we may well be able to proactively regulate our gene expression so that we never get cancer, or rheumatoid arthritis, or atherosclerosis, or diabetes.

But it is going to be a long time before the biological revolution pays off in the way Zerhouni envisions. In the meantime, I don't hear him saying much about the work we need to do to make medicine truly integrative -- of body, mind, spirit and society. We may have a magic nano-bullet that stops diabetes in its tracks by the year 2020, or we may not. But meanwhile, we know that our present epidemic is created by social conditions -- mass marketing of cheap, sugary foods; and sedentary lifestyles spent in front of computer and TV screens and riding in cars. We can't do much to prevent some cancers, but we can prevent an awful lot of cancer by eliminating tobacco use and cleaning up our air and our work environments. Same with heart disease. And no matter what miracles come out of the laboratories, we will still be mortal and we all need to face death eventually, and no doubt sickness and disability before it comes.

Finally, we need to ask whether these miracles of the future will be available to everyone, or only a lucky few, mostly in the rich countries. Social inequality is responsible for most of the world's burden of disease and early death. The cure for that is not going to be found in a laboratory.