What holds medicine back? Medicine has advanced rapidly during the last half century but things have apparently slowed down a bit recently. Perhaps it is true that all the easy discoveries have been made and only the difficult ones remain. In any case, this is as good a time as any to look at the very varied factors that are holding medicine back. The Royal Society of Medicine in London recently called together distinguished (perhaps too distinguished) speakers to discuss what they described, in elegant prose, as "Constraints on the advance of medicine".1 Before examining constraints, however, one should look at the goals. What would or could medicine really achieve if it were allowed to operate without any obstacles in its path? Cynics might make some tart remarks about rapid overpopulation and a geriatric society, but even the optimists would find the question hard to answer. At the London symposium Burgen suggested, as befits a pharmacologist, the development of effective antiviral agents (with a possible impact on cancer) and a better understanding of the neurochemical basis of behaviour as conceivably attainable targets, with comprehension of the cause of atherosclerosis as a less likely but highly desirable achievement. Godber, a retired "man from the ministry", gently hinted that the freedom of the doctor to follow his own beliefs might itself be a constraint on progress, although he made reassuring noises about the improbability of a British government's attempting to lay down approved patterns of medical work on the Russian or Chinese model. However, he agreed with many that the most severe constraint of all is the proportion of gross national product allocated to health (in the United King-
dom only two thirds of the Canadian expenditure). We should by now have learned the lesson that from now on a system of priorities in medicine will become increasingly necessary. The big problem in the doctor's mind is: who will determine the priorities and on what basis will the choice be made? Godber indicated that the old system, by which doctors determined their own priorities on a personal basis, must go and that the problem cannot be solved by giving medicine a bigger share of the national cake. Availability of resources obviously has a bearing on advances in medicine because determination of priorities will in future also 'influence the support of research. Scarcity of resources will dictate more cooperation and less overlap; if results are to be suitably applied to community health, cooperation must extend beyond the confines of the profession and include other sections of the population. Obstacles to progress do not entirely lie outside the medical profession, as Godber had already pointed out. At a session on intraprofessional obstacles Doll mentioned two important obstacles to epidemiologic research, the trend towards destruction of medical records and the present, sometimes unreasonable outcry over invasion of privacy. Access to personal information must be permitted if the public is to be protected against the hazards of living in a highly industrialized society. That hospitals are handicapped in research by lack of funds was the complaint of Peart, who also deprecated the public hysteria about experiments on patients. There are four main difficulties in the way of drug development, according to Weatherall of the Wellcome Research Laboratories: the approaching shortage of raw materials, the enorm-
ous growth of legal requirements devised to ensure drug safety but now an obsession hampering therapeutic advance, the emotional reactions of the public as exemplified by their current fear of drugs and their concern about animal experiments, and the growing costs of drug research. The cost of discovering a new drug and marketing it has increased 50-fold in 20 years, far beyond the general rate of inflation. That the public resistance to innovation is a powerful constraint was indicated by Williams, an economist, and by an editor, Butt, who argued that patients' needs should play a part in determination of priorities. Williams thought that research would be better directed to assisting the community than to gaining academic applause; Butt believed that research directed at increasing the comfort of the patient could be more useful than some more scientific fields of enquiry. O'Donnell, a medical editor, did his best, with the help of some figures, to destroy the myth that something called "public opinion" actually exists. Public mood, a better term, has had little effect on the course of British research so far. Having spelled out the obstacles to advances in medicine, the next step is to consider their removal. Black and Clarke wrestled bravely with this problem. Their efforts deserve reading in extenso, if only to reveal the complexity of the situation. Since Homo sapiens has been displaying rather less sense than usual in his behaviour in recent years, as any analysis of world news will show, it is unlikely that the situation will improve rapidly. Reference I. Constraints on the advance of medicine. Proc R Soc Med 67: 1273, 1974
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dom only two thirds of the Canadian expenditure). We should by now have learned the lesson that from now on a system of priorities in medicine will become increasingly necessary. The big problem in the doctor's mind is: who will determine the priorities and on what basis will the choice be made? Godber indicated that the old system, by which doctors determined their own priorities on a personal basis, must go and that the problem cannot be solved by giving medicine a bigger share of the national cake. Availability of resources obviously has a bearing on advances in medicine because determination of priorities will in future also 'influence the support of research. Scarcity of resources will dictate more cooperation and less overlap; if results are to be suitably applied to community health, cooperation must extend beyond the confines of the profession and include other sections of the population. Obstacles to progress do not entirely lie outside the medical profession, as Godber had already pointed out. At a session on intraprofessional obstacles Doll mentioned two important obstacles to epidemiologic research, the trend towards destruction of medical records and the present, sometimes unreasonable outcry over invasion of privacy. Access to personal information must be permitted if the public is to be protected against the hazards of living in a highly industrialized society. That hospitals are handicapped in research by lack of funds was the complaint of Peart, who also deprecated the public hysteria about experiments on patients. There are four main difficulties in the way of drug development, according to Weatherall of the Wellcome Research Laboratories: the approaching shortage of raw materials, the enorm-
ous growth of legal requirements devised to ensure drug safety but now an obsession hampering therapeutic advance, the emotional reactions of the public as exemplified by their current fear of drugs and their concern about animal experiments, and the growing costs of drug research. The cost of discovering a new drug and marketing it has increased 50-fold in 20 years, far beyond the general rate of inflation. That the public resistance to innovation is a powerful constraint was indicated by Williams, an economist, and by an editor, Butt, who argued that patients' needs should play a part in determination of priorities. Williams thought that research would be better directed to assisting the community than to gaining academic applause; Butt believed that research directed at increasing the comfort of the patient could be more useful than some more scientific fields of enquiry. O'Donnell, a medical editor, did his best, with the help of some figures, to destroy the myth that something called "public opinion" actually exists. Public mood, a better term, has had little effect on the course of British research so far. Having spelled out the obstacles to advances in medicine, the next step is to consider their removal. Black and Clarke wrestled bravely with this problem. Their efforts deserve reading in extenso, if only to reveal the complexity of the situation. Since Homo sapiens has been displaying rather less sense than usual in his behaviour in recent years, as any analysis of world news will show, it is unlikely that the situation will improve rapidly. Reference I. Constraints on the advance of medicine. Proc R Soc Med 67: 1273, 1974
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