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Fundamental Questions in Medicine

A new editorial by Simon Levin in PLoS Biology has the thought provoking title “Fundamental Questions in Biology”. It set me thinking what the fundamental questions in medicine now might be, and, perhaps even more importantly, what’s going on to address them. Medical journals have an opinion (sometimes too many opinions) about what these priorities should be and can attempt to influence the policy agenda by encouraging papers on a particular topic, but we are not the ultimate arbiters.

Off the top of my head, here are some suggestions – feel free to disagree.

How are western countries going to afford to pay to pay for the advanced care that many patients have now come to consider a human right?

Conversely, what will it take to provide the necessary impetus to provide cures for the most neglected diseases of the developing world? (see also the recent blog post by Gavin Yamey)

Why are so many people willing to accept the unproven benefits of some alternative medicines yet are so suspicious of some highly effective interventions, such as vaccination? Have the practitioners of conventional medicine lost the trust of patients?

Why has the huge death toll caused by road traffic accidents worldwide failed to outrage the public and make policy makers take action?

What’s to be done about the pandemic of obesity and its related diseases in the Western world? Surely this is related to our willingness to let children eat poor quality, high-calorie food; in the UK school food has become a hot political topic.

How can the enormous technological advances of basic science such as genome sequencing and stem cell research be harnessed for the good of global health. One new initiative that might be able to coordinate efforts has been annnonced by the US’s National Centre for Biotechnology Information, NCBI. The Whole Genome Association will manage the “submission, storage, and access for clinical phenotype measures and associated whole genome genotype data”.

If you’ve got opinions on these questions, let us know. You never know, we might get to change an agenda or two.

  1. Those sound like fundamental questions at the interface between politics and medical care delivery. Which is great, but makes me wonder: Do we not have any remaining Fundamental Questions about Disease? (fundamental meaning, I guess, that the question is not just about some one disease, but relates to many.) I would be interested in seeing nominations for such questions; here are a few of mine:

    1. A great many diseases seem to have very substantial but less than total heritability (e.g., if your identical twin has schizophrenia, your chances are perhaps 50%–far more than baseline but far less than 100%). Is this pattern telling us something interesting?

    2. Stomach ulcers seem to be a case where decades of research documented what are now regarded as basically exacerbating factors, with an infectious agent being the most fundamental cause (or so most people say, at least). Will this turn out to be a very common scenario for idiopathic chronic diseases?

  2. A wonderful list. I’d say that we do indeed have many more unanswered fundamental questions about disease — but I trust that those questions will continue to be asked (and answered) by scientists, whereas I’m not so sure about Virginia’s questions. My 2 cents, in order:

    Western countries aren’t going to pay unless they have single-payer systems. The people who want the procedures are going to pay; those who need them but can’t pay won’t get them.

    As for developing countries, the impetus will be what it is elsewhere: profit. Make it worth their while, and companies will figure out what to do. I doubt very sincerely that governments will.

    Yes, practitioners of conventional medicine have lost their patients’ trust, but it’s not their fault, I don’t think. This question has been vexing me for a long time. I think the fundamental problem is that most people don’t understand how science works, and therefore any anecdote is equi_valent to evidence. No matter how well-designed the trial that produces the evidence, true believers will find a nit to pick with it. The test population was the wrong one, the researchers confused cause and effect, the timing was wrong, the concentration was too small…

    The death toll on our roads raises no alarm because it doesn’t happen all at once, and it rarely makes the news. It’s precisely because it’s so common that it’s lost its power to worry us.

    As for the pandemic of obesity, maybe poor-quality food has something to do with it. But we ate crap all the time when I was a kid, and we’re only now getting this fat. I say, turn off the electronics. Unplug the little buggers and make them go play outdoors, fer pity’s sake.

    As for your last question… I honestly have no idea. I don’t know enough about science to guess at possible applications, and I have a sneaking suspicion that this question tends to double back and intertwine itself with the first two. That is, it intersects with financial motives and political will.

  3. In light of the launch of PLoS Neglected Tropical Diseases, one of the 10 fundamental questions for medicine ought to address the issues surrounding the neglected tropical diseases. For example,the lack of attention paid to this group of diseases by the worldwide medical community, specifically in the western world and what can be collectively done by the worldwide community to raise the profile of these diseases that affect the most vulnerable of the world population (which is of substantial size).

  4. What are the most likely spatiotemporal patterns of HIV incidence for the _next_ 25 years and, consequently, which interventions will be most effective within and between different countries?

  5. We also have to decide, as a society, how many resources to dedicate to prevention. You mention prevention of chronic conditions from obesity, but there is also occupational health and safety, automotive safety (accidents are leading cause of death in people ages 20 to 40), etc.

  6. I’m an engineering student and happened to come across an article on pH of blood in which it says the arterial partial pressure of oxygen and carbon dioxide is 90mmHg and 40mmHg respectively. But the total arterial blood pressure is 120mmHg and from the article oxygen and carbon dioxide alone accounts for more than that(90+40). Could anyone please explain this.

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