Chapter 8 medical technology

Our country has had to spend enormous sums of money on some scientific undertakings in order to satisfy its own needs.For these undertakings, technology assessments have become routine.Astute committees are continually evaluating the effectiveness and cost of various activities in space technology, defense, energy, transportation, etc., in order to inform how to prudently invest in the future. But somehow the medical business, despite being said to cost our country more than $80 billion a year, has not received much of this analytical treatment.People seem to take it for granted that medical technology just exists, and it's all the same as it is.The only major technical issue of interest to policy makers is how to provide equitable access to the health services that exist today for all.

Sooner or later analysts will have to turn to medical technology, and then they will have to face the problem of how to weigh the relative costs and effects of everything that is done to control disease.That's what they eat, and I wish them well.But I can imagine that they will have a dizzy day.Because on the one hand, our approach to disease is constantly changing—partly influenced by new information from all aspects of the biological sciences; Not at all. In fact, there are three levels of very different technologies in medicine that are so different from each other that they are not an activity at all.Physicians and analysts will get into trouble if these three levels of technology are not separated from each other.

1. First of all, there is a large part of technology that can be called "non-technology".These technologies cannot be measured by their ability to alter the natural course of a disease or alter its ultimate outcome, and a great deal of money is spent on it.Not only patients, but medical professionals also speak highly of it, and it includes what is sometimes called "supportive care," which helps patients heal from ailments that are not generally understood.This is what words like "care" and "maintenance" refer to.This technology is irreplaceable, but it is not really a technology because it does not involve measures to target the disease mechanism.

Any good doctor spends a great deal of time assuring, explaining to the patient that he is in fact healthy when he suspects that he has an incurable disease of one kind or another.This kind of thing falls into this category of "non-technical". What physicians used to do at the bedside of patients with diphtheria, meningitis, polio, lobar pneumonia, and all the other infectious diseases that were later brought under control also fell into this category. Physicians today must do the same with patients with the following diseases.These conditions include recalcitrant cancer, severe rheumatoid arthritis, multiple sclerosis, stroke and advanced cirrhosis.One can think of at least twenty major diseases for which such supportive care is not yet available.I myself would include a large number of so-called mental illnesses and most cancers in this category.

This non-technical expense is high and keeps getting higher.It not only takes a lot of time, but also requires the hard work and superb skills of physicians.Only the best doctors are good at picking up this kind of defeat.It also means long hospital stays, lots of nursing care, and involves a lot of non-medical professionals inside and outside the hospital.In short, this therapy makes up a significant portion of healthcare costs today. 2. One level higher than non-technical is a certain kind of technology, which is better called "half technology".These are some things that must be done after the fait accompli has happened.There are diseases whose course you can do little and whose disabling effects you have to work hard to compensate for.This technique is used to compensate for disease consequences or to delay death.

Prominent examples in recent years have been the transplantation of hearts, kidneys, livers, and other organs, as well as the equally impressive invention of artificial organs.In the eyes of the public, such technologies seem to have become synonymous with high technology in the natural sciences.The mass media tends to report each new procedure as if it represents a breakthrough and a therapeutic triumph rather than an actual stopgap. In fact, this level of technology is both highly developed and very primitive in nature.This is something one has to keep doing until the disease mechanism is truly understood.For example, in chronic glomerular nephritis, it seems that the allergens that cause allergies restrict this disease, and it is these allergens that cause necrosis of glomeruli.We have yet to understand these situations better before we know how to intervene judiciously to stop this process or turn it in the opposite direction.When we reach this level of understanding, kidney transplantation will not be of much use, and will not have the enormous logistical, cost, and ethical problems it has today.

In order to control coronary heart disease, extremely complex and expensive technology was invented, including specialized ambulances and hospital wards, all kinds of electronic gadgets.There are also many new professionals to deal with the late symptoms caused by coronary thrombosis.Almost all the methods used to treat heart disease today are at this level of technology, and the most advanced ones are heart transplants and artificial hearts.When people know enough to understand what goes wrong with heart disease, they should be able to figure out ways to prevent or reverse the process.Once that happens, the current set of painstaking techniques will likely be put aside.

Much of what is done in cancer treatment—surgery, radiation, and chemotherapy—is half-baked.Because these measures all point to the cancer cells that have already formed, rather than the mechanism of cells turning into neoplasms. This type of technology is characterized by a large cost of money and requires constant expansion of hospital facilities and an endless need for new highly trained personnel to operate the business.And, in the present state of knowledge, there is no other way.If building a few specialized coronary care wards can prolong the lives of a few coronary patients (no problem, the technique is effective in a minority of cases), then the inevitable situation will arise: how many such The wards will be built as many as they can be found, and will be spent as much as they can be found.I don't see anyone having any other choice.The only thing that keeps medicine apart from this level of technology is new knowledge, and the only source of that knowledge is research.

3. The third category is those technologies that are so effective that the public seems to pay the least attention; such technologies have been taken for granted.This is a truly decisive technique in modern medicine, best exemplified by modern immunization methods for diphtheria, whooping cough and viral diseases in children.Among them are the contemporary methods of using antibiotics and chemotherapy to deal with bacterial infections.Being able to effectively combat syphilis and tuberculosis represents a milestone in human endeavor, although this potential has yet to be fully exploited.There are other examples, of course: the use of appropriate hormones to treat endocrine disorders, the prevention of hemolytic disease of the newborn, the prevention and treatment of various nutritional disorders, and perhaps the just emerging approaches to Parkinson's and sickle cell anemia.There are other examples, and everyone can come up with some favorite candidate list, but the reality is that there are far fewer diseases that can actually be effectively treated than the public believes they can.

This kind of real medical high technology is the result of a real understanding of the mechanism of disease, and once it becomes feasible, it is relatively economical and relatively easy to administer. I cannot at the moment think of any important human disease that medicine is capable of preventing or curing when the cost of technology is a major concern.To deal with the same disease, at the initial stage of non-technical or semi-technical, the cost is incomparably high.If a case of typhoid fever had to be treated today with the best methods of 1935, the cost would be staggering.For example, it required 50 days of hospitalization, requiring the most troublesome nursing care, as well as dizzying requirements for dietary details, which was one of the characteristics of the therapy at that time, daily laboratory tests, and sometimes surgery to deal with it. Bowel perforation.I think, to deal with this disease in this way, ten thousand dollars is still a conservative estimate, but what is the price today?Just a bottle of chloramphenicol and a day or two of fever. In the early 1950s, just before the basic research on the use of vaccination to prevent polio was undertaken, the fledgling technology for combating that disease provided another piece of evidence for this thesis.Remember Nurse Kenny (Sister Kenny, Elizabeth, 1880-1952, Australian)?The cost of those institutions for the rehabilitation of poliomyelitis patients, and the soothing application of warm compresses, as to whether the affected limb should be rendered completely incapacitated, or should be passively moved as often as possible. Remember the debates, and the piles of data that were statistically tossed around to support one opinion or another?These are the costs and relative effects of that technology, which should be compared with the cost and efficacy of vaccination.

Tuberculosis has had similar episodes in its history. In the early 1950s there was a sudden surge in surgery to remove infected lung tissue, and there were elaborate plans to install new and expensive equipment for major tuberculosis operations in tuberculosis hospitals.Then, isoniazid and streptomycin came along, and those hospitals closed down. Health care system inefficiencies are most pronounced when physicians are bogged down by their imperfect skills and doing things without a clear understanding of disease mechanisms.If I were a policymaker interested in saving money for health care in the long run, I would be prudent to give a high priority to basic research in the biological sciences.This is the only way for medical science to gain the full benefit of biology, even though it seems, as it is often said in old days, to pluck the moon.