technology lecture: technology and medicine

Technology Lecture: Technology and MedicineAuthor(s): Christopher BoothSource: Proceedings of the Royal Society of London. Series B, Biological Sciences, Vol. 224, No.1236 (May 22, 1985), pp. 267-285Published by: The Royal SocietyStable URL: http://www.jstor.org/stable/35877 .

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Proc. R. Soc. Lond. B 224, 267-285 (1985) Printed in Great Britain

TECHNOLOGY LECTURE

Technology and medicine

BY SIR CHRISTOPHER BOOTH

Clinical Research Centre, Watford Road, Harrow, Middlesex HAI 3 UJ, U.K.

(Lecture delivered 24 October 1984 - Typescript received 15 November 1984)

[Plate 1]

Technology, which is older than science, has been of vital importance in the development of modern medicine. Even so, there are voices of dissent to be heard. The disenchantment with technology expressed by Aldous Huxley in Brave new world has been echoed by contemporary writers on the technology of modern medicine. Medicine is seen by some to have been dehumanized by technology, and techniques that are expensive are thought to be consuming a greater proportion of health resources than they deserve. The practice of medicine has, nevertheless, been transformed by modern technology and diagnostic techniques and therapeutic measures undreamed of a few short decades ago are now commonplace. There is no reason why these developments should be any more dehumanizing than the use of similar techniques in modern transportation or communication, nor is their expense out of proportion when compared with other demands on the nation's purse.

British workers have been at the forefront of many recent advances. Yet, even though the National Health Service provides a ready market for the products of British medical technology, the nation depends to an inordinate degree on imported products. In the development of appropriate medical technology there is an urgent need for better communication between inventors, scientists, industrialists and the National Health Service. At the same time there is an equal need for improved evaluation of untried techniques. The pressure for a central integrating body to coordinate resources could well be supported by the establishment of evaluation units in the different health authorities in this country.

Technology is as old as man. As Benjamin Franklin aptly remarked, man has always been a tool-making animal, and it was his capacity to make tools that led to the development of crafts such as carpentry, building, metal-smelting, weaponry, leather-tanning, weaving and so on. From these crafts there emerged through the centuries the technology that has become one of the four environments within which man lives, the others being the cosmic, the natural and the social.

Science, however, has a different tradition and is a more recent development in man's history. It belonged originally to mathematics and astronomy or to the aristocratic speculative philosophy of the Greeks and Romans, and became the

[ 267 ] Vol. 224 B (22 May I985)



268 Sir Christopher Booth

experimental science we know today only after the Renaissance. For the ensuing centuries, science and technology were largely divorced from each other, pursuing different paths, not only as a result of class division but also because initially the work of the scientist in his laboratory had little relevance to that of workers, craftsmen and metal founders who were developing their own technology. It was not until after the industrial revolution that science and technology came together and that technology became more firmly based on science. Von Liebig, for example, was the father of organic chemistry and it was his basic scientific discoveries that were to lead to the development of the first synthetic fertilizers; and Faraday's work was the scientific basis upon which Edison and Swan developed the technology of the electric lightbulb.

Medicine and medical technology have evolved in a similar way. As with many of man's other practical activities, medicine first developed as a craft and from ancient times technology has, therefore, been an essential part of its practice. One of the earliest of medical technologies was applied to the treatment of broken limbs. The splinting of the legs of Egyptian mummies is an example of prehistoric medical technology that serves to emphasize that medical technology has always been with us.

As in other fields of human activity, so in medicine in the modern era, science has become increasingly important. Yet it is clear that the translation of scientific discovery to clinical practice requires the interposition of technology (figure 1). This is a two-way process. It is often technology that makes possible scientific discovery and medical practice itself prompts the development of new technology as well as suggesting problems for science. In fact a fair proportion of the science of medicine comes directly from the clinical field and the work of clinical scientists, whose ability to apply knowledge is vital to any success science may have in influencing medical practice. The representation in figure 1 of the interplay between these different but related activities as a biological reaction emphasizes the need for a close, harmonious and creative relationship between scientists, technologists and those involved in the practice of medicine, something which as we shall see is not always as well developed in Britain as it should be.

science technology clinical research and practice

FIGURE 1. Relation between science, technology and clinical research and practice.

This paper first sets out to classify the technology currently in use, then describes how it has been developed, and what has constrained it. The questions whether we can afford modern technology and how better our manufacturers could do are then discussed. Finally, how shall we both encourage and control medical technology?

There is a vast range and complexity of medical technology in routine use. Table 1 attempts to classify medical technology. Technology may first be diagnostic, it may be therapeutic, or it may involve monitoring devices for both



Technology and medicine 269

diagnostic and therapeutic purposes. It can also be preventive, remedial or involve information systems.

Diagnosis (table 2) begins in the doctor's surgery or clinic and has always traditionally involved the stethoscope, invented in France by Laennec in the early 19th century (Laennec I8I9). There are now a wide range of different techniques available for clinical diagnosis. Inspection of organs has been made particularly simple by the introduction in recent years of flexible instruments and it is now possible to introduce a fibre optic instrument into any available orifice and be rewarded with a remarkable view. The use of flexible sigmoidoscopes for example, permits the examination of the entire colon by physicians expert in this technique (Matsunaga & Tajima I969).

TABLE 1. CLASSIFICATION OF CURRENT MEDICAL TECHNOLOGY

1. diagnostic (clinic) pathology laboratory imaging 2. therapeutic (surgery) artificial organs radiotherapy 3. monitoring (ambulatory) intensive care anaesthesia 4. preventive 5. remedial and supportive 6. information systems

TABLE 2. SOME TECHNIQUES AVAILABLE FOR CLINICAL DIAGNOSIS

stethoscope breathing tests blood pressure measurement visualization of organs - opthalmoscope

laryngoscope flexible endoscope

electrocardiograph electroencephalograph biopsy techniques - liver, kidney, intestine amniocentesis for antenatal diagnosis computer diagnosis

Biopsy techniques have been of particular importance for medical diagnosis. One of the most ingenious devices, invented some time ago by an American army haematologist, Colonel W. H. Crosby, was a capsule for taking biopsies of the small intestinal mucosa, the lining membrane of the intestine where absorption occurs (Crosby & Kugler I 957). The capsule is swallowed on the end of a fine tube. A little knuckle of intestinal mucosa is sucked into it, then a rubber sheet beneath the knife bulges up to release a spring and a piece of tissue is obtained. With a low power dissecting microscope, this technique at once demonstrates the difference between the normal appearance of the intestinal mucosa and the abnormal flat mucosa of an individual who has a sensitivity to bread causing coeliac disease (figure 2, plate 1). This can be done as an outpatient during a morning and has completely eliminated the need for complex tests of absorption involving hospitalization which used to be necessary for diagnosis. It is an excellent example of how important simple low-cost technology is for the practice of modern medicine.

Computer-aided decision making in medicine is still relatively undeveloped but

10-2




Spiegelhalter (I984) states that in the ten years to 1983 the Index Medicu8 showed that the number of articles under 'computers' and 'decision-making' more than doubled, an encouraging sign to those who seek to increase the accuracy of clinical diagnosis in this way.

TABLE 3. DIAGNOSTIC TECHNOLOGY IN PATHOLOGY LABORATORIES

haematology counting of blood cells blood transfusion techniques

chemical pathology measurement of substances in body fluids radioimmunoassay

histopathology diagnosis of cause of disease cytogenetics diagnosis of genetic abnormalities

for example, Down's syndrome biotechnology DNA probes in antenatal diagnosis microbiology identification of microorganisms

serology

The next line of diagnostic technology is in the pathology laboratory (table 3). Blood haemoglobin levels and cell numbers have to be measured automatically in large and complex machines. The measurement of substances in body fluids also involves complex and expensive automated machinery so that a whole range of tests of different substances in the blood can now be rapidly provided. The use of radioactive tracers and of radioimmunossay have also been of great importance in this field. Histopathology and cytogenetics still rely on microscopical analysis and the use of the human eye, but the identification of different types of cell using modern techniques, particularly the use of monoclonal antibodies to individual cell constituents, is promising to revolutionize this speciality. The use of DNA probes for the antenatal diagnosis of genetic disorders is one of the exciting areas of modern medicine where techniques of molecular biology are being applied to human problems. Until recently the identification of bacteria in the laboratory has been a time-consuming business, with predominantly traditional techniques carried out by hand, but there is a new age of automation on the horizon and a fully automated bacteria identification system has recently been developed which is being introduced into microbiology laboratories (Tabaqchali et al. I984).

One of the important features of this increase in the use of automated machines for laboratory tasks has been the extraordinary escalation of numbers of tests asked for by clinicians. Figure 3 shows the numbers of samples (in millions) sent nationwide to chemical pathology laboratories during the 1970s. This steep increase reflects a commendable investigative zeal yet it is by no means certain that it has brought comparable benefits to the sick and suffering.

It is in the field of diagnostic imaging (table 4) that the most expensive techniques have been developed. X-ray machines for radiological examination have always been expensive and complex modern equipment for ultrasonic examination is increasing in price yearly. But it was the introduction of computerized X-ray tomographic scanning that led to an escalation of costs of an entirely



Proc. R. Soc. Lond. B, volume 224 Booth, plate 1

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Technology and medictne 271

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FIGURE 3. Escalation in numbers of blood samples sent to clinical pathology laboratories in England 1972-1978. Redrawn from figure 1 of Fleming & Zilva (i98i).

TABLE 4. IMAGING TECHNIQUES

conventional X-ray ultrasound digital subtraction angiography radioisotope scanning positron emission tomography CAT scanning nuclear magnetic resonance

new dimension. The technique is particularly useful for the diagnosis and treatment of head injuries, a problem in both the young and the elderly, and in the management of cancer.

The latest development in this field is nuclear magnetic resonance (n.m.r.). This technique, which depends on the ability of a large magnet surrounding the body to interact the nuclei of atoms in cells with an applied magnetic field, allows the different tissues of the body to be made visible without recourse to radiation and there is, therefore, no radiation hazard. Nuclear magnetic resonance for imaging body organs, pioneered by E. R. Andrew in this country, is still in its development and assessment phase but it has already proved its value in providing images of brain and other organs which are vastly superior to those obtained by other techniques.

But n.m.r. is not used only for imaging. One of its most exciting applications is for the study of metabolic reactions of different organs in the body in vivo, as Radda's team at Oxford are showing with M.R.C. support (M.R.C. News I982). At University College Hospital in London, similar techniques are being used to detect anoxia in the brain of newborn babies.

Among therapeutic techniques, surgery has been practised since at least the time



272 Sir Christopher Booth of the ancient Egyptians, and the use of instruments to facilitate childbirth has a long history. There are now lasers, cryosurgery, and machines that will dissolve renal stones by sonication. These techniques, together with the use of organ transplantation, heart-lung oxygenators, renal dialysis machines and cardiac pacemakers have transformed the practice of medicine in the past three decades. Techniques for the successful transfusion of blood and other fluids have also been of vital importance for modern surgery, as well as for resuscitation. They are essential for the replacement of blood loss following haemorrhage and the treatment of some varieties of anaemia associated with bone marrow failure.

Radiation therapy has been extended to include the use of neutrons produced by very expensive cyclotrons. Technology has always been a useful aid to obstetricians but the pioneering and wholly remarkable work of Steptoe and Edwards has now developed a reproductive technology reminiscent of Aldous Huxley's Brave new world, even if we do not yet have Bokanovsky's process or Podsnap's technique. Open heart surgery to undertake valve replacement has dramatically changed the lives of individuals who are otherwise doomed to a distressing death from heart failure, and artificial kidneys and renal transplantation have successfully extended the lives of sufferers from kidney failure for whom medicine previously had nothing to offer.

Anaesthetic techniques may be appropriately classified as therapeutic procedures. They include the use of machines of increasing complexity. There is a whole technology associated with the supply of anaesthetic gases and anaesthetists are also particularly interested in monitoring techniques which are a sort of 'automatic pilot' for the anaesthetist. It is perhaps worth recording here that anaesthetists are now the single largest specialist group in the National Health Service.

New techniques are also changing professional practices. Traditionally, operative techniques have been carried out by surgeons, physicians contenting themselves with diagnosis and the use of drugs. Now, however, radiologists are doing operations on blood vessels and with the advent of fibre-optics, physician- gastroenterologists are exploring the biliary and pancreatic passages, slitting the ampulla of Vater which leads these passages into the duodenum, and removing gallstones (Cotton I 984), something that was always the prerogative of the surgeon in the past.

Monitoring devices are now available that can measure physiological changes in the human body over prolonged periods of time. They can be used either upon an ambulatory patient, to determine the effect of a drug on heart rate or blood pressure, for example, or in the intensive therapy unit where they have proved of particular value in the care of babies born prematurely. By using this sort of technology the blood pressure can be measured over a 24 h period. This enables the investigator to study the Circadian rhythms of blood pressure in normal people, for example, and in those with hypertension. In this field the availability of computerized analysis has been essential. The most important uses of monitoring techniques are in childbirth and in the intensive care situation, and the successful survival of infants weighing no more than 500-700 g at birth may now be confidently predicted.

Preventive technology includes vaccines, the possible prevention of dental caries




and birth control. Vaccines were first developed when Edward Jenner introduced the technique of vaccination in 1798. It has to be admitted that two years before that date his preliminary work had been turned down by Sir Joseph Banks, then President of the Royal Society, when it was submitted for publication in the Society's Philosophical Transactions (Booth I 98 I). Despite the total eradication of smallpox throughout the world nearly a decade ago by the World Health Organization, by using the same technique that Jenner introduced, his work remains important since it is now possible, with modern biotechnology, to use the vaccination method and incorporate other antigens which can induce immunity to other diseases.

Another interesting preventive technique is emerging in the dental field. Dental sealants are liquid plastic resins which are applied to the biting surface of the posterior teeth. Caries usually begins at the bottom of a fissure on the biting surface of the teeth, where bacteria ferment dietary sugar to produce acid and, therefore, caries. This can be prevented by the use of a dental sealant, the fissure being closed by the layer of clear plastic material which is resistant to acid, and which solidifies on exposure to light.

Birth control is perhaps one of the best examples of the use of both technology and science in medicine. Satisfactory mechanical methods of birth control, which have evolved immeasurably since the use of animal bladders and bits of intestine in the time of James Boswell, have been due to the use of new technology in the production of thin and reliably strong sheets of rubber. By contrast, the use of the rhythm method of contraception and of the contraceptive pill, owe every- thing to Corner's careful scientific elucidation of the nature of the menstrual cycle and the discovery of progesterone in his laboratory.

TABLE 5. SOME EXAMPLES OF REMEDIAL AND SUPPORTIVE TECHNOLOGY

artificial joints and limbs spectacles artificial teeth splints aids for elderly aids for blind wheelchairs cars for disabled hearing aids

Remedial and supportive technology (table 5) is a field that encompasses an enormous range of important activity. As the years go by, life becomes increasingly dependent on prostheses and since so many people are living to an advanced age this is an important area of medical technology. The number of centenarians in the United States is currently considered to be as many as 12000 (Budd I982) SO

that there is a great opportunity, which Professor Heinz Woolf and his colleagues at Brunel University are seeking to exploit, to use technology in the service of the elderly. At the same time the disabled and the handicapped deserve as much help as modern technology can give them.

Information technology is also an area in which there is a great opportunity for the future. In health education as well as in the education of the individual patient with a specific complaint such as diabetes, there is great scope for the development of educational videos, computer programs and films. Medical records sadly remain



274 Sir Christopher Booth one of the problem areas of the National Health Service. Attempts at computerization, photographic recording, miniaturization and standardization are in their infancy. It is a field of medical activity which intelligently used modern information technology could surely improve. It is encouraging that the North West Thames Regional Health Authority are making a start at St Mary's Hospital with the computerization of X-ray records.

So far as the provision of health services is concerned, one of the major effects of the development of technology has been on manpower. An army of technicians and other health personnel is now required to run the machines and carry out the techniques of modern medicine. At the beginning of the century in the United States, about 345000 people were estimated to work in health care and, of these, one in three was said to be a physician. By 1940, specialization of the non-physician work force was keeping pace with specialization among doctors, for by then there were 27 new and recognized non-physician occupations including physiotherapy, dental hygiene, radiological technology and so on. By 1976 the United States health workforce had grown to about 5.1 million and only 1 in 13 of these was a physician (Reiser I982). The allied health occupations (excluding nurses, and nursing auxiliaries) contained 155 recognized specialities in 1976. The approximate figures of staff for the N.H.S. in 1984 are shown in table 6. The total number of staff employed by the N.H.S. exceeds one million. There are approximately 29000 general practitioners, 38000 hospital medical and dental staff, an army of nurses and midwives and a large number of non-medical scientific staff.

TABLE 6. STAFF EMPLOYED BY NATIONAL HEALTH SERVICE (1984)

general prac-titioners 29000 medical and dental 39000 nursing and midwifery 391000 professional and technical 65200 ambulance 18200 ancillary 172000 works and maintenance 27000 administrative and clerical 108000

How has new medical technology developed and what has encouraged its development? The sequence of events shown in figure 1 that indicate that science leads to technological development and then to its application in practice holds true for the story of the development of antibiotics, vaccines such as those that have eradicated poliomyelitis and currently for the application of the techniques of molecular biology to human problems. One may be led by these developments to conclude that in encouraging technological progress in medicine it is essential to support basic science. There is good evidence to support this view. Comroe & Dripps (I976) made a detailed study of the scientific basis for the support of biomedical science with particular reference to the fields of cardiac and pulmonary medicine. They wished to examine the view expressed by President Lyndon Johnson and based on a study of how 20 important military weapons came to be developed, that too much basic research was being done, that life-saving discoveries




might have been made that were, in Johnson's words, 'locked up in the laboratory' and that therefore there should be more targeted or mission-oriented research. It was a viewpoint reflected in the Rothschild proposals for the organization of government research in this country.

Comroe & Dripps (I976) first identified the top ten clinical advances that they and a team of 40 other physicians considered to be the most important for their patients. They then identified 529 key articles that were considered to be essential for these advances. These were assessed as being either clinically oriented, or not. Their conclusions were that 41 % of the work judged to be essential for later clinical advances was not clinically oriented at the time that it was done. This is a powerful argument for the support of basic research but their study also shows that a large proportion of work considered important for advances in cardiac and pulmonary medicine was in fact clinically oriented. Furthermore, more than 15 0 of the key publications in the field were concerned with the development of new apparatus, techniques or procedures. Their work, therefore, also makes a compelling argument for effective research support in the clinical field as well as in technology. This is an important conclusion for those concerned with the support of medical research in this country. The Medical Research Council has the responsibility of supporting the whole of biomedical research from the molecule to the community. Himsworth, a much respected secretary of the Medical Research Council, has recorded that in the mid 1930s a President of the Royal Society found it incumbent on himself to write to the then Secretary of the M.R.C. to protest publicly against the, to him, unwarranted diversion of funds for the support of work in the clinical field and in Himsworth's own time, he records that he was not immune to attack for, as he put it, 'wasting money on clinical research' (Himsworth I982). At a time when funds are increasingly constrained, there may well be attempts to hijack the funds that should properly go to clincial research. This would be unfortunate, for a study of the development of modern medicine shows how vital it has been to support clinical research and in particular to encourage brilliant and innovative doctors, who have the important responsibility of applying science and technology to medical practice.

There are many examples of the way in which pioneering medical practitioners have developed new technology. Renal dialysis machines were first developed by Willem Koli, a Dutch physician who emigrated to the United States, and in this country it was Melrose, a surgeon, who pioneered the use of heart-lung machines, although in this case the M.R.C. declined to support the work as too technological. Charnley, an orthopaedic surgeon, was the innovator who made hip replacement operations possible. Dr Martin Wright of the Clinical Research Centre invented the machines we use to measure the flow of air in and out of the lungs, and he has also invented a number of accurate infusion pumps. His latest, the size of a wristwatch, is an effective artificial pancreas which will deliver insulin as required. In addition, the initial development of transplantation techniques was pragmatic and owes as much to the doctors who pioneered the use of renal dialysis and to Alexis Carrel's techniques of vascular suturing as to the brilliant work of immunologists in the laboratory.

The story of the development of fibre-optic instruments, is perhaps worth




recording in more detail since it illustrates the interplay between the ideas of intelligent clinicians, the work of a brilliant innovative British scientist, and the extraordinary ability of the Japanese to exploit someone else's discovery. It began when a British gastroenterologist, Dr Hugh Gainsborough of St George's Hospital in London, met Harold Hopkins, who was then working at the Imperial College of Science and Technology. Gainsborough, to use Hopkins' own words, was 'pretty well appalled by the use of the old rigid gastroscope' which required the skill of a sword swallower on the part of both operator and patient (H. H. Hopkins, personal communication). He asked Hopkins whether it would not be possible to have something flexible like a rubber gastric tube which could be swallowed much more easily. It was this suggestion that encouraged Hopkins to think about the matter. As few months later he formed the idea of a coherent glass fibre bundle for carrying an optical image along a flexible path. With his graduate student N. S. Kapany, he was able to produce a successful image-transmitting bundle and the work was soon published in Nature (Hopkins & Kapany I954). There were, writes Hopkins, many enquiries following the publication of this article, but sadly none from industry.

One, however, was from a British gastroenterologist, Dr (now Sir) Francis Avery Jones, who encouraged one of his young men, Dr Basil Hirschowitz, to follow up Hopkins' discovery. Hirschowitz had by now moved to Ann Arbor, Michigan, where he successfully developed a prototype. The next step was clearly the production of a commercially viable instrument by industry but this was to prove much more difficult than the early experimental work. At first no industrial firm in the United States or in Britain was willing to help develop the fibrescope. Finally, American Cystoscope Makers Inc. (A.C.M.I.) agreed to make the fibrescope under licence (Hirschowitz I979) but it was not until four years later that the first results from the use of commercial endoscopes were published in the Lancet (Hirschowitz I 96 I).

The remainder of the story, as is well known, belongs to Japan. In 1962, Professor Tadayoshi Takemoto imported a commercially available Hirschowitz gastroduodenal fibrescope from the United States. The moment was particularly propitious, for Japan at that time provided a particularly fertile field for the development of fibre-optic endoscopy. Japanese surgeons working in Tokyo, concerned at the high incidence of gastric cancer in their community, and with the aid of the Olympus company had already developed a tiny camera attached to a fine cable that could be swallowed into the stomach for the purpose of early diagnosis. More than 1000 patients had been examined in Tokyo University by this technique.

There was, therefore, in Japan a community of physicians and surgeons, as well as a commercial organization, highly sympathetic to the use of new techniques in the investigation of gastrointestinal disease. It was in this favourable environment that Takemoto, together with the Machida Company and with Olympus, rapidly developed the new generation of fibre-optic instruments for endoscopy that have literally swept the world. The first endoscopes were on the market within a year ofTakemoto's importation into Japan of the Hirschowitz instrument (T. Takemoto, personal communication).




There are a number of lessons to be learned from these stories. First, that in the development of new technology a close association of innovative medical men with scientists and engineers, and particularly with those working in thrusting commercial enterprises, is essential; second, that there is often a compelling clinical need (in the case of fibre-optics a high incidence of gastric cancer); and third, that there should be a social milieu, as in Japan, where technology and applied science are highly regarded. There is also the vexed question whether, as the Science Policy Research Unit has put it, this country might profitably engage in a greater level of research forecasting (Irvine & Martin i 983). They have concluded unequivocably, but with provisos, that the United Kingdom should attempt to bring its long-term forecasting up to the remarkable level they identified in Japan.

Hopkins himself, asked why we were so sadly not able to develop fibre-optics in this country, blames first the appallingly low standard of general and technical education in the commercial firms that existed at that time; second, the lack of risk capital; third, and above all, the lack of vision and confidence in what was possible from both the technical and commercial point of view.

Has anything changed since then? The successful development in recent years of CAT scanning in this country and now of n.m.r. suggests that it may have, but at the same time there is evidence that the British health care industry, if one excludes pharmaceuticals, is not at present rising to the challenge that the technology of modern medicine presents. Although, the United Kingdom health care industry has, at least until recently, been in positive trade balance with the rest of the world, an analysis of the results of recent years is not encouraging, as it shows a persistent deterioration in the United Kingdom's position (figure 4). This

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FIGURE 4. Balance of payments surplus in U.K. medical equipment industry 197G-1982, expressed in constant value terms corrected to 1982 figures. (Courtesy of G. R. Higson.)

picture is not specifically a feature of medical equipment since it also applies to the whole field of scientific instrumentation (Schott I984). Scientific officers who are responsible for the purchase of medical scientific equipment find that the situation is frankly depressing. Dr Harold Glass, Senior Scientific Officer at the North West Thames Regional Health Authority, writes that most of the ultrasonic




equipment he purchases is Japanese or American, as is virtually all the major biochemistry and haematology equipment. Microscopes are usually German or Japanese, and pathology equipment is becoming increasingly Japanese in origin. Indeed the major British X-ray company, Picker Ltd, tends to incorporate large amounts of Japanese, Italian and French electronics in some of its products. The most popular general purpose X-ray table is imported from Belgium, the generators are manufactured in Italy and its sophisticated imaging and image processing equipment tends to come from the United States. The general picture from a British manufacturer's point of view appears to be becoming progressively worse each year. On the computer side, although major orders have been placed by health authorities with a British firm for patient administration systems, there is a continuing and increasing tendency to purchase many smaller similar systems from American manufacturers (H. Glass, personal communication).

What is contributing to our lack of success? There appear to be a number of factors which include British attitudes to technology, unsatisfactory relationships between industry and academe, a relatively small home market and the influence of budgetary constraints in the National Health Service.

It is platitudinous to say that one of the major contributing factors remains attitudes to technology and applied science, but it must still be said. Medawar had pointed out that 'Britain suffers from that most dangerous form of snobbism in science ... which draws distinctions between pure and applied science... and which is at its worst in England' (Medawar I979). In our schools any one who is 'any good' is encouraged to do academic things and engineering and applied sciences are regarded as lesser pursuits. This carries forward into university life and later into professional careers. It is a viewpoint reflected by the comment of a certain medical scientist that the award to Hounsfield of the Nobel Prize for the introduction of CAT scanning had only been given for 'mere technology'. One is reminded of the immortal reply made to Brunel when he told a lady that he was an engineer, and she commented that she had mistakenly thought that he was a gentleman.

Medical attitides may also tend to be against technology. The keystone of most doctors philosophy is primum non nocere and so they are in general not the wild enthusiasts for new technology that some social analysts believe them to be. They usually follow the policy of being neither the first to start something nor the last to give it up. The medical reaction against new technology was perhaps best illustrated by the very strong initial opposition to the introduction by Sir John McMichael of invasive techniques of clinical investigation such as liver biopsy and cardiac cathetization, which in fact soon became routine. Furthermore, among clinicians who are expected to replace an established technique with a new one, there is often as much opposition as may be expected from a working man threatened with the obliteration of his job.

Yet there is more to the downgrading in our society of technology than the attitudes of academic or professional men. In an era when the threat of nuclear war is ever present, there has been a strengthening of the anti-technology lobby worldwide. There is nothing new in the attack on technology. The dire predictions that were made when railway trains were introduced, Ralph Waldo Emerson's




warning during the heyday of Victorian technological progress that 'things are in the saddle and ride mankind' and Henry Adams' reactions to what he saw as the excesses of technology when he visited the Paris Exhibition of 1900, were later echoed by the disenchantment with technology expressed in Aldous Huxley's Brave new world and in Charlie Chaplin's film Modern times, where the deperson- alizing effect of a contemporary production line was brilliantly depicted.

In recent years populists have sought to sow a mistrust of scientists and technology in the public mind. This has been accompanied by assaults on modern medicine by writers such as Illich (I977) and the B.B.C.'s Reith lecturer for 1980, Ian Kennedy, as well as by doctors themselves. McKeown (I 976), among others, has argued that medical science and technology have been given too much credit for the improvements in the nation's health during the past century and in particular that the decline in mortality from infectious disease is due more to social change than to science and technology. By contrast, he might now reflect that it is social change that has led to the current world epidemic of sexually transmitted disease and in particular, to the tragedy of AIDS. Since epidemiologists are unlikely to succeed in changing sexual behaviour, it must be emphasized that it is only science that has anything to offer to the unfortunate sufferers from these unpleasant and sometimes fatal conditions, as is illustrated by the recent discovery that a specific retrovirus is associated with AIDS (Barre Sinoussi et al. 1983; Gallo et al. 1983).

Whatever may be said about technology and medicine by populists, epidemiologists, cost analysts and others, the one group that appears to be in favour are the patients whom we seek to help. This is even true in the field of obstetrics, where there are many women's groups opposed to what they consider to be interference with nature. A recent issue of Hospital Doctor has published the results of a survey of 1000 women giving birth at Queen Charlotte's Hospital with the arresting headline 'Women give thumbs up to high tech birth' (Fitchew I984).

Apart from attitudes to technology there is considerable evidence that the relation between industrial laboratories and academics in the field of bioengineering and medical physics has never been as well integrated as in the field of pharmaceuticals. In the medical equipment field, Brian Pullan, a distinguished ex- academic who has now founded his own successful business, has reflected on the reasons for this (B. R. Pullan, personal communication). Career structures and motivation, he points out, are very different in industrial and non-industrial environments. In universities and institutes of higher education the pressure is to publish completed pieces of work gaining the most prominent position possible in the list of authors. By this means prospects of acquiring grants and thereby publishing more papers and ultimately gaining promotion are improved.

There is consequently a reluctance on the part of academic researchers to allow a commercial enterprise to get involved before the work is complete and full academic credit has been gained. This results in delay in the commerical exploitation of ideas, a damaging release of key information to foreign competitors through freedom of academic communication, and, because apparatus has usually been made without the involvement of professional engineers, an unnecessarily difficult problem of re-engineering.




By contrast, in the world of commerce, there is a desire to get a product to the market place as soon as possible. Products are normally marketed as soon as they are judged to be saleable and often contain many faults which are cured in later models. This has the commercial advantage that a quick return is achieved, and in addition later models make earlier models obsolete well before they have come to the end of their useful life, thus leading to renewed sales. This commercial approach, which is pursued to some extent by all companies, does not go down very well in academic circles.

Another cause of conflict identified by Pullan, which may result in ineffective collaboration, is that the academic usually tends to overvalue his ideas and often does not understand the very large gap between a single working laboratory prototype and a commercial unit. The latter has to be made in large numbers with a high reliability and with operating and service manuals, together with servicing, marketing and sales support. All this costs money and highly skilled effort. The initial development, which is all that the academic sees, is a very small part of the overall task of commerical exploitation of an idea or invention. This simple fact is not widely appreciated outside industry.

TABLE 7. APPROXIMATE VALUES (EM) FOR U.K. HEALTH CARE INDUSTRY (1982) medical equipment

pharmaceuticals and supplies U.K. production 3000 800 U.K. market 2400 750 (N.H.S. in brackets) (1400) (650) exports 1000 350 imports 400 300 positive trade balance 600 50

(Courtesy of G. R. Higson)

There are, however, other more tangible influences upon the medical equipment side of the health care industry in this country. The first of these is the relatively small home market provided by the United Kingdom. The relative values of pharmaceuticals and medical equipment and supplies in this country for 1982 are shown in table 7. The pharmaceutical market is clearly booming and it is interesting that in this field there has never been the same separation between academe and industrial laboratories, as well as clinical practice, that Pullan describes. Contacts between research workers in commercial and academic laboratories have always been close, as is so clearly shown by the career of Sir Henry Dale who worked respectively in a university, with Burroughs Wellcome, and with the Medical Research Council. Clinicians, particularly those who accept free rides on the Orient Express, have in fact been criticized for being too close to the pharmaceutical industry. It is, however, worth reflecting that it may well be that this proximity has contributed to the success of the drug companies in this country.

The home market for equipment and supplies is smaller than that for pharmaceuticals and smaller, too, than that in the United States, Germany and




Japan. This may be a reflection of the fact that these countries, as is well known, allocate a greater proportion of their gross national product to health than we do. The proportion of g.n.p. devoted to health in this country is about 6 %, whereas it is more like 8 0 in other countries in Western Europe and 10 0 in the United States. So far as market size is concerned, however, the situation for our industry could surely be corrected by a more aggressive British apprQach to the European market. Whether British firms are sufficiently expert linguistically to achieve this is uncertain, since language teaching, like technology, remains another of the defective areas of our educational system. There is also to some extent a conflict of interest between the medical equipment industry and the National Health Service. Budgetary controls at Regional and District Health Authority levels are a constraint to buying new technology, while the interests of industry demand, by contrast, a buoyant market. This is not to say that the N.H.S. inhibits industry. The Department of Health and Social Security (D.H.S.S.) through its Scientific and Technical Services Branch has funds available to support new initiatives, which it has effectively done, and it also seeks to ensure that medical equipment should be safe and fit for its purpose (Higson I984). More than 200 British Standards have now been established by the D.H.S.S. for medical equipment and supplies, and most manufacturers agree that only firms that comply with quality standards should be in the medical business. All this is to the good. Nevertheless, the situation in the N.H.S. is quite different to that in a system of medicine controlled by the private sector and private insurance companies, where the cost of any new equipment or technology is simply added to the patient's bill. Medical technologies have therefore in the past been introduced, particularly in the United States, without real knowledge as to their cost: benefit ratio.

Banta (I982) in examining the escalation of health care costs in the United States, has pointed out that the major root of the technology problem is the open ended re-imbursement system which pays for almost anything recommended by health care providers. Now, however, both the United States government through its Medicare and Medicaid programmes and the insurance companies are intro- ducing an agreed series of investigations for therapeutic procedures which will be re-imbursed only if the clinician follows the agreed procedure. We have not yet reached that point in this country since the stricter budgetary controls imposed in the N.H.S. do not yet make it necessary. However, a move towards increasing private practice in this country would inevitably increase the use of technology and equipment in the private sector, which might well escalate medical fees and costs without a proportionate increase in benefit to patients. Such a move would therefore require controls.

The continued concern with escalating health care costs has, however, led many to conclude that it is technology that is the major cause of increasing expenditure. At the same time, terms such as 'high technology medicine ' or 'expensive medical techniques' are introduced, implying that these techniques are the bogey men in our health care system. In fact, they only account for a relatively small proportion of total health care costs, which are due immeasurably more to manpower and to the widespread use of minor and low cost technology throughout the entire health service. Such low cost technology, which as I have pointed out is essential to the




practice of modern medicine, tends to be neglected by contemporary analysts. Nevertheless, as G. R. Higson (personal communication) has shown, the simple replacement of porcelain for gold in the manufacture of dental crowns saves ?26 a time, which at 25000 crowns a year is ?600000.

Furthermore, if we look at the capital costs of even the most expensive medical techniques such as n.m.r., CAT scanning, renal dialysis and coronary artery bypass grafting, to say nothing of cardiac transplantation, they are very much less than comparable costs for extracting oil from the North Sea, communication by satelite, travel by Concorde, or the extraordinarily high expenditure on defence. One may well suspect that terms such as 'high technology medicine' have a touch of the perjorative about them and may reflect, albeit unconsciously, the disenchantment view of technology rather than being solely the result of a concern with costs.

The Council for Science and Society (I982) has published the report of its working party on what it calls 'expensive medical techniques', which it carefully does not define. The vast majority of individuals working in health care would agree with the working party's views, reinforced by the arguments advanced by Jennett (i984) in a recent Rock-Carling Monograph, that assessment is necessary when new techniques are introduced. After all, the rejection of Jenner's work by Sir Joseph Banks was on the correct grounds that the technique of vaccination had not been validated. As the Council for Science and Society explain, there is clearly room for improved methods of evaluation of new as well as of old techniques. There is clearly a need for more specialist advice, more research and a greater degree of consultation. But modern technology, whether it is expensive or not, does not emerge from the consensus of committees but from the innovative and fertile minds of individuals, and if we are to make progress in the future it is such individuals that we must cherish and encourage.

The Medical Research Council has the responsibility of promoting a balanced development of medical and biological research rather than undertaking programmes directed at commercially desirable objectives. Nevertheless, through its close association with the British Technology Group, Celltec, and directly with other commercial organizations, the M.R.C. has a commendable record in encouraging new technology. The development of the techniques of molecular biology and of the use of monoclonal antibodies is largely due to the M.R.C.'s influence, particularly to the exciting work of distinguished scientists such as Cesar Milstein at Cambridge. It is also worth recording that a simple method for measuring cholesterol in the blood, developed by a research officer at the M.R.C.'s Clinical Research Centre has been one of the top six money spinners of the British Technology Group (1981-82). Nor is the M.R.C. inactive in the equipment field. An automated machine invented by the Divisions of Clinical Chemistry and Bioengineering at the Clinical Research Centre, which will selectively measure up to 24 different blood constituents, has been developed to commercial production, sadly not with a British firm. It is now in use in the Clinical Chemistry Department at Northwick Park Hosptial.

So what of the present position? Clearly the initiatives currently being launched by Sir Alistair Pilkington and the British Association, such as the publication of the new magazine Link-up, may encourage a higher regard for technology in our




society and greater communication between industry and the academic world. So, it is hoped, will these lectures at the Royal Society. It is difficult to say whether there is enough venture capital available to sustain an innovative and successful medical equipment industry in this country, but there are many who feel that the root problem in Britain is not a lack of money for technological development but a lack first of ideas and second of that sort of fizzing critical mass that is immediately apparent if you visit Silicon Valley in the United States. A recent newspaper report suggested that there was not a single comparable critical mass in Great Britain today, which may be true in the field of applied technology.

It is unquestionably not true, however, for medical research where it is lack of money rather than lack of ideas that is currently the problem. The M.R.C.'s Laboratories for Molecular Biology in Cambridge are effectively a Silicon Valley for this country in their field and the current cuts in the M.R.C.'s budget are, therefore, a threat to some of the best scientific work being carried out in the world today. Since the development of much of modern biotechnology has derived its impetus from the work of these laboratories, to cut the M.R.C.'s funds is a short-sighted policy. Equally, it is vital to the development of the National Health Service that we encourage the emergence of the innovative young people in the clinical field who can effectively apply scientific knowledge, and this too is threatened by the M.R.C.'s increasing inability to fund clinical research of high quality.

It has been repeatedly urged by those concerned with health care costs that new technology requires better evaluation and the Council for Science and Society (I982) has proposed, as well as others (Jennett 1984; Lancet 1984), that there should be a central integrating body to coordinate this task. In view of the problems that have been identified in this lecture, however, it would be preferable if such a body were to have the additional responsibilities of identifying promising future areas of applied research and stimulating new ideas, as well as fostering links between the academic world, the National Health Service, research and industry. Whether such a body were to form part of a projected institute of medicine on the United States model, and what its relationship should be to the D.H.S.S. and the British Technology Group would require further assessment. The idea, however, is worth exploring, as is the further suggestion that in the National Health Service technology advisory groups should be set up at regional and district level.

There is no reason to suppose that the pace of advance in man's technological environment will slow down. Already biotechnology promises to revolutionize medicine, not only in the diagnostic and therapeutic fields but also in prevention. Voices will no doubt continue to be raised against technology, not just on grounds of cost but also because it is considered to be dehumanizing. The old image of the caring, compassionate doctor has been replaced in some minds by that of a medical Dr Strangelove, in love with techniques for their own sake and the patient becomes a mere body surrounded by machinery.

There is, however, no reason why medical technology, used with the compassion and understanding that is a feature of all good medicine, should be any more dehumanizing than technology applied to travel or communication. Furthermore,




the works of the great painters, musicians and scientists of the past are surely no greater an reflection of the nobility of the human spirit, than are the scientific and technical achievements of modern medicine. There is no field of human endeavour, other than the feeding of the hungry, to which the ingenuity of man can be better devoted.

I thank many friends and colleagues for their helpful advice during the preparation of this paper, but my particular thanks go to Dr Barbara Stocking, Mr G. R. Higson, Dr Harold Glass, Professor B. R. Pullan and to my colleagues in the Medical Research Council.

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technology lecture: technology and medicine

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