Introduction:

Ladies and Gentlemen,

It is a very distinct pleasure to welcome you here, to the Library of Alexandria, reborn after an absence of 1600 years. The Bibliotheca Alexandrina’s ambition is to once more bring world-class learning, intellectual dialogue and scientific discourse to the very spot where the ancient Library of Alexandria once stood.

Yours is the first science group we host in the new library, a few weeks before our official opening. Please forgive the incompleteness of some of the services as we race against time in the final countdown towards the official opening on April 23, 2002, the international day of the book.

How appropriate that this gathering should be a meeting of physicians. Alexandrian medicine played an important part in the ancient world, bringing as it did two great traditions: the Greek and the Egyptian into a spectacular fusion that was to advance medicine to a plateau where it was to stay for over a thousand years.

The ancient Library of Alexandria started as the Mouseion (the museum) a temple to the muses where the most eminent scientists, philosophers and artists would meet and study and discuss. It was a gathering of brilliant minds devoted to rationality, dialogue, understanding and openness to the other.

On this very spot…

• Aristarchus was the first human being to say the earth revolves around the sun;
• Eratosthenes proved that the earth was spherical and calculated the circumference of the earth to the amazing accuracy of some few percentage points;
• Hipparchus calculated the length of the solar year to within 6 minutes;
• Euclid wrote the elements of geometry,
• Manetho chronicled the pharaohs and gave the dynasties the names we use to this day;
• Herophilus identified the brain as the key to control of the body…

The great Library disappeared 1600 years ago, overwhelmed by a wave of zealotry that would not tolerate scientific inquiry or philosophical questioning or the opening to the other.

Modern Egyptian medicine, which is so ably represented here tonight, is also the product of opening unto the “other”, the modern west. Mohamed Ali Pasha established the Qasr al-Aini School of medicine in 1827. Fifty years later, Sonbol tells us, Egyptian medicine had been transformed from a largely medieval practice to a modern one. It went on to become better and better, and some of Egypt’s most eminent physicians are practicing at the most distinguished institutions in the world …

• Today you bring the practice of medicine in Egypt to the cutting edge of world knowledge.
• Today a great global revolution is looming in medicine
• Today the Bibliotheca Alexandrina is preparing to once more become the place to discuss the ethics of science and its application, to be the window of the world on Egypt and Egypt’s window on the world.

And today, I am most privileged to deliver The Ibrahimian lecture, named in honor of a great Egyptian pioneer, Dr. Mohamed Ibrahim, who is the person most responsible for the establishment of cardiac surgery in Egypt. I am delighted that his son, Professor Mohsen Ibrahim is with us tonight. We are all in his debt, as his example continues to inspire generations of practitioners.

A visionary, he cultivated the healthy skepticism of true scientists, and remained devoted to the noble vocation of healing. To his memory, a profound salute. I hope that he would have approved of what I am about to say.

My themes for today:

Throughout the long history of humanity, the art of healing the sick has been the most respected of vocations, and the most appreciated of sciences. Yet the understanding of that long history is flawed, I believe, by the intertwining of two distinct aspects of the question that blur our understanding of many realities. These are public health and individual (private) medicine. Only recently have those two common threads been disentangled (mostly in the last century, but possibly starting in the middle of the nineteenth century).

It is of these two threads -- public health and private medicine—that I want to speak today.

First , I will trace the development of medicine from its origins through its three modern revolutions; and assert that despite the potential of the new scientific revolution in the biological sciences that is at our door, the medical profession is entering a period of deep self-examination, and potential crises due to the perceived divergence of the two threads.

Second , I will argue for a new view of medicine that can hopefully help weave the strands together in a strong and sturdy line, a new thread of Ariadne for our times, to help get the public and the practitioners on the same plane as the scientists all working for the common good of humanity.

Third , and to conclude, I will attempt to sketch out a vision of the future of medicine in this new century.. A future that you will forge by dint of your example and the values that you will instill in your students…

So let us start with a brief retrospective…

The evolution of modern medicine: a retrospective

In history, we sometimes refer to revolution.. The industrial revolution, the informatics revolution.. We tend to use these terms to mean major shifts in the sweep of history that have been marked by substantial changes in the condition of massive numbers of people around the planet. Rarely can one pinpoint a single date or event for this transformation. But the history of any topic, and medicine is no different, is not only subject to such sweeping revolutions, but is also punctuated by the highpoints of individual achievements that have marked the milestones of the road to these broad transformations.

So shall it be in my talk today. Broad changes referred to as revolutions and a salute to the major events that punctuate history, the individual achievements that remain an inspiration to us all to this day.

The first revolution in medicine:

It is widely agreed that medicine has gone through a number of genuine revolutions. For myself, I place the first medical revolution in the domain of antiquity, with the Egyptian Imhotep as its greatest protagonist. Imhotep, a genius by any measure, builder of the great stepped pyramid of Zoser at Saqqara, was justly immortalized as the Egyptian god of medicine, and his renown as a physician was sustained over millennia, not just centuries.

That first revolution was the adoption – at least by some—of the view that disease had a cause and could be cured, and was not just something that had to be endured. Careful observation, experiment and the seeds of the scientific method of empirical trial and error can be traced back to those dim days of early antiquity. These approaches lead to a variety of treatments, some effective and some totally dubious, if not downright harmful, but they implied belief in the agency of the treatment, including surgery, to effectively bring about a change for the better.

The second part of that first revolution came when the efforts were systematically codified into a corpus of knowledge and organized along inductive and deductive lines. The Greek physicians, disciples of Aescalepius and students of Hippocrates, made major contributions to this development but it was in ancient Alexandria that it would truly flourish.

Alexandria was to witness a huge expansion in the contributions to medicine. Herophilus, who lived in the heady days of the flourishing Library of Alexandria, was the first to bring to bear rigorous anatomical study with major efforts at functional analysis. He not only correctly identified the brain as the key organ of intelligence – as opposed to Aristotle who had argued for the heart – but he also named the duodenum and made many other relevant studies, including the early identification of blood circulation and the measurement of the systolic and diastolic rates of the pulse. Herophilus and his colleague/student Erasistratus were to found the two most successful schools or houses of medicine in ancient Alexandria.

The last of the truly great physicians of the ancient world, Galen, studied at Alexandria before heading back to his native Pergamon and from there to Rome to treat, inter-alia, the emperor Marcus Aurelius and his deranged son Commodus.

Thus the first medical revolution was started millennia ago, and gave us some insights, some names, some treatments, the Hippocratic oath, and little else. These products found their way to the 18th century largely unimproved.

The torch was passed from the Hellenistic physicians to the Muslim scholars like Al-Razi and Ibn Sina (Avicenna to the Europeans). They were the great codifiers, organizing all the known knowledge in encyclopedic works that defined medieval medicine for hundreds of years, till the well past the renaissance. Yet we cannot pass in silence over the enormously fascinating – and largely unacknowledged in the west -- contribution of Ibn Al-Nafis who was undeniably the first to truly describe the circulation of the blood in 1288, long before Harvey.

This was well before the 16th century anatomical studies of Andrea Viselius or the 17th century work of William Harvey, modern discoverer (exponent?) of the circulation of the blood (1628). But Andrea and Harvey represent a transition in the west insofar as they were believers in observation and experimentation, not the power of the views of the ancients.

The three revolutions of Modern Medicine:

In recent times medicine can count three major revolutions, overlapping and continuing, reinforcing each other to bring better health care to people all over the world. Health care involves both preventive and curative aspects.

Let me define the start of recent times with the late 18th century perhaps, with an accelerating series of major contributions that gradually replace our ancient/medieval worldview with something approximating the modern worldview.

And the honor roll is splendid, to name but a few:

• 1798 Edward Jenner starts vaccination against smallpox
• 1840s sees the discovery of anesthesia for surgery
• 1850s Claude Bernard elucidates the endocrine functions
• 1859 Charles Darwin changes our view of nature and other species through evolution
• 1865 Lister invents surgical antisepsis (using carbolic acid)
• 1880s Pasteur launches bacteriology
• 1895 Rongten discovers X rays
• 1890s and early 20th century Freud and Jung and others plumb the psyche

But while these punctuating highlights were indeed steps that increased our knowledge of the human body and of the vectors of disease, the net result in terms of massive improvements in human well-being were being silently forged elsewhere. The first great medical healthcare revolution was not wrought by doctors at all…It was the work of engineers!

In the 19th century and early 20th century, the systematic establishment of proper water works and sanitation in most major cities was probably the first major revolution in public health, and it did very significantly reduce the massive problems of water borne diseases that still plague so much of the developing world, where as much as half of humanity lacks adequate sanitation and about a sixth lack access to safe drinking water, with concomitant infant mortality rates and low life expectancies.

The next two revolutions were indeed the results of medical research and medical practice:

The second revolution came from anesthesia which made surgical interventions much more bearable, while the use of Lister’s antisepsis approach reduced infections. Surgery, with us from the time of Imhotep, came of age in the last hundred and fifty years or so.

The third revolution was the pharmacological revolution which came about with the discovery of antibiotics and the much more effective use of chemical medicines. To this must be added the very widespread use of the vaccines that prevented many of the dreaded diseases of the past. Today in the advanced industrial countries, vaccines—direct descendants of Jenner and his milkmaids—are so common that many scourges have become all but unknown. Not just smallpox, which has been eradicated worldwide, but polio, tuberculosis, measles, rubella, and many other childhood diseases that claim millions of infants worldwide have been largely prevented through systematic vaccination programs.

Today a new medical revolution is brewing. It is being formed in the womb of the rapidly developing revolution in the biological sciences.

Today the biological sciences are on the threshold of a revolution as profound and as exciting as that of physics in the glorious forty years 1905-1945, when all the concepts were changed, from cosmology to atoms, from relativity to quantum mechanics. Nothing would be the same again. Today in biology we are decoding the genomes, we are harnessing bacteria to do our work and we are learning to tinker with the very building blocks of life…

And yet, despite its great achievements, the medical profession itself is at a crossroads. To understand that, let us backtrack a bit and disentangle the two threads I mentioned at the outset: the medical treatment of individuals and the public health aspects of the management of healthcare. Sub-themes exist in each of these two main threads.

On Public Health and Private Medicine

Medicine and public health have become intertwined in the public mind. Yet they are very different things, and though mostly complementary, they can nevertheless sometimes work at cross-purposes.

The first, medicine, is largely focused on the health of the individual. The second is focused on the average health of the entire population measured statistically. Kerr White identified the year 1916 as the decisive point at which in the United States that distinction became clear. The Rockefeller foundation started funding the establishment of the first schools of public health independent of schools of medicine. Richard Horton attributes to this decision the “…abandonment of the social impulse within American medical education. This division contributed to the origination of two distinct histories of western medicine, histories that had until then been indivisible.”

The divergence of the two histories as Horton sees it can be immediately grasped if we review what the Centers for Disease Control and Prevention consider the ten greatest milestones of public health:

• Vaccination
• Motor vehicle safety
• Safer workplaces
• Control of infectious diseases
• Declines in death from coronary and heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Fluoridation of drinking water
• Recognition of tobacco as a health hazard

No medical procedures figure in that list. Increasingly, people view national policy, public education programs, sound diets and lifestyles, counseling, vaccination, and environmental hygiene as keys to the preventative medicine and public health. This is in contrast to the deepening focus of individual treatments of severely sick persons, which remains at the heart of the individual medical practitioners professional sense of pride.

Bringing these two strands together is at the core of the challenge of transformation of medicine for the new century.

The Transformation of Medicine today

The fundamental shift from individual medicine to public health is the shift from curative to preventative as well as the shift between the concerns with the health of individuals to the health of entire populations.

The conflict arises when the allocation of funds is at stake. The role of research and of public support programs is an issue:

How much new technique is required versus making what is already known more accessible to larger numbers of people?

How much to develop new treatments versus how much to accelerate the transition of treatments from lab to patients and to scale up the application of known beneficial care to large numbers of individuals?

The issues are being complicated by the evolving nature of the medical and public health enterprises.

On the medical side:

• Enormous specialization
• The fragmentation and complementarity of much health care
• Divergence between research and clinical work,

And then there is the manner in which the enterprise is undertaken.

Clinical trials increase. Mark Chassin observed that in 1966 there were 100 clinical trials randomized controlled trials in peer-reviewed journals. In 1995 there were 10,000. Yet these studies do not bridge the gap between the research and the practitioners who become increasingly identified as separate communities.

On the public health side the issues are somewhat different: Concern with the public–private divide is growing more acute. The role of private providers of treatment (big pharmaceutical companies as well HMOs) vies with a perception of profit versus need. It is noteworthy that “The current profit margins of the US pharmaceutical companies is in the range of 18%. They have a substantial R&D commitment, but also spend 40% of their money on marketing and relate activities.”

I am not faulting private companies, I am faulting public authorities that forget that public goods (in economic terms) must be funded by the public purse. Adam Smith, father of the invisible hand said in “The Wealth of Nations”:

“…the state is responsible for ‘erecting and maintaining those public institutions ... which though they may be in the highest degree advantageous to a great society, are, however, of such a nature, that the profit could never repay the expense to any individual or small number of individuals, and which it, therefore, cannot be expected that any individual or small number of individuals should erect or maintain.”

That is the case with vaccination, environmental hygiene and much of the preventative aspects of public health. So the shifting boundaries of the public and private domains in the provision of health services remains an area of concern and one where many of the issues of the new century shall play out…

Today’s institutional arrangements are also part of the problem, because they are perceived as competitive rather than complementary, and because we do not effectively weave into a common fabric the roles of the many who labor in the domain of health. And they are many.

Eli Ginsberg observed that in 1927 there were two “health providers” (Health-care workers) for every physician in the United States. By 1999 there were sixteen. We need teams to provide excellent care. Teams working in hospitals, in schools, in community centers, all working like musicians in an orchestra, playing different music but the whole producing a great symphony … The whole is greater than the sum of the parts…

To achieve this we need two things, and they start with the medical doctors: First, to change the notion of solo practice. Second, to rethink the prevailing values of medical practice in the last twenty years or so.

Keneth Shine, President of the US Institute of Medicine, in his farewell speech last October called the medical profession a cottage industry! He said:

“We are the largest cottage industry in the world. We have huge cottages that have various types of technology in them. They have poor communication, both internally and externally.”

And there is much to support that view. Computer records are driven by specialized studies of cardiac care or children’s cancer… but not systematically to cover the whole population of patients. Much less the whole external population.

Managing this huge data will require IT, which offers enormous potential for system-wide connectivity, potential that is still sorely underutilized. Setting up such system-wide approaches would be costly, but not as costly as many other areas of expending funds today.

Are we paying for increasingly minor variations of an existing technology? Is there redundancy in the system? How much additionality is there in the variations from cat scans, MRIs etc.? Here it is pertinent to ask: Are we paying for major advances or minor variations? Variations that do not actually advance the treatments much?

While recognizing that many technologies advance incrementally, we still need to question the emerging pattern of research and practice in a place like the US which spends infinitely more than many European countries and whose bio-medical research enterprise is justly envied across the planet, still ranks very low on indicators of overall health of the population and of the dispersal of those indicators over the various sub-groups of the population.

So, as we enter the 21 st century, the work of medicine has now broken down into its constituent parts. The researchers are increasingly separated from the clinicians among the doctors, the physicians now rely on armies of specialized health personnel and the bio-medical enterprise churns on with all the constituent parts….

The public health enterprise is connected but separate from the medical enterprise. The focus on prevention does occasionally come together (annual checkups, mammograms, child vaccinations,…)

And on the horizon looms the promise of the great biological revolution…

Visions for tomorrow:

Allow me now to get into really difficult territory: Predictions.

I predict that the transformation of medicine and public health in the 21st century shall indeed take the path of integrating the health care professions into a true system of healing and health.

Let me to sketch out the likely scenario of this development:

The next twenty years are going to bring us face to face with a profound confrontation of the privatization of science, and the patenting of knowledge. New ethical dilemmas shall be highlighted as we debate medicine as a commercial service and public health as a public good. The trigger of the dispute will be the price of medicine, especially in the less developed countries. We have already seen this in the case of AIDS and we will see it repeated in the case of other medicines, linked directly to the new rounds of global trade talks following on the Doha WTO meetings.

The next twenty years will also see a whole new approach to bio-ethics as the new technologies open up avenues that hitherto remained in the domain of science-fiction, and as public fears of scientists running wild will try to curb research. I predict that reason will prevail, and scientific research will continue apace.

The future is being framed by the new biology. The promise of the genome is only going to be realized over the next two decades. Proteomics will complement the genomics we have come to know. Establishing the Proteome, the total protein complement of the human cell, will open up whole new vistas for medical research and application.

The 2020s shall see the transformation of the practice of medicine from the largely solo practice that exists today towards the establishment of truly integrated systems of healthcare.

So:

Instead of solo practice, we must think of systems of care…

Instead of visit-based care, we must think of continuous healing relationships…

Instead of professional autonomy driving variability, we must think of customized care according to patient needs…

Instead of professionals controlling care… we must think of the patient as the source of control

Instead of information as a record, we must think of shared knowledge and information flowing freely.

These are the hallmarks of the new 21st century integrated system of medicine and health care…

A system where decision making will increasingly be evidence based. Transparency shall replace secrecy. Safety shall be a system property, not just an individual responsibility to do no harm. A system where cooperation among clinicians shall be the norm, and where waste is continuously decreased rather than seeking cost reductions by HMO management fiat…

By the middle of the century, the revolution will be almost complete: the new treatments will be in place, and the practice of medicine will have experienced as profound a transformation in those 50 years as was experienced in the years between the 1920s and the 1970s.

But whereas the closing decades of the last century saw only incremental improvements, the second half of the 21st century will see dramatic new shifts in the very concept of treatment as the genetic revolution takes hold: from switching the genes on and off, and the coding for particular proteins, the replenishment of particular constellations of cells, the re-growth of organs at will, and so much more…. all of that will become possible and feasible. The world of our grandchildren will be a truly different one from our own.

Envoi:

Ladies and Gentlemen,

We have come a long way in the last thirty minutes: From ancient Alexandria through the Middle Ages to the pride of modern medicine… We traced modern medicine through its three revolutions:

• Public health water and sanitation
• Anesthesia and surgery
• The pharmacological revolution and anti-biotics

And we looked into the pending fourth great revolution as we realize the promise of the new biology.

We tracked the divergences and the coming together of public health and private medicine, rejecting the false dichotomy and recognizing the inescapable complementarity between the health of individual patients and the average health of entire populations.

We peered into the future and what the 21st century can hold…

And in all this, you have been patient travelers and explorers, for like all doctors, you are committed. Scientists, you are committed to the search for truth, … Healers, you are committed to the betterment of the human condition…

Together we have searched and explored in our hearts for what is right, for us, for our children and for the world, and like all explorers …

        "We shall not cease from exploring

       And at the end of all our exploring

       Will be to arrive where we started

       And know the place for the first time."

              …(T.S. Eliot)

Thank you.