¿Cuál es la mejor medicina?


Illustration for article titled What's the Best Medicine?

Illustration: Benjamin Currie (Gizmodo)

Giz AsksIn this Gizmodo series, we ask questions about everything from space to butts and get answers from a variety of experts.  

Thousandsofmedicineshave made it to market in the last century or so. Some of these medicines have single-handedly eradicated illnesses that have plagued humanity from the dawn of time; some have made chronic conditions at least somewhat more tolerable; others have plunged people into sleepless hallucinatory hell-worlds from which no amount of therapy (or lawsuit money) could ever save them. For this week’sGiz Asks, we’re interested in that first category—the paradigm-shifting, life-restoring, legitimately sort of miraculous medicines which have periodically brightened the planet. Below, a number of historians of medicine weigh in with their picks for the all-time best medicine.

Bert Hansen

Professor, History of Science and Medicine, Baruch College at the City University of New York, and the author ofPicturing Medical Progress from Pasteur to Polio

Though it’s surprising to many, the medicine with the single greatest impact was Louis Pasteur’s invention of rabies shots. It rocked the global media in 1885. Rabies was an uncommon, but always lethal disease, and it loomed large in people’s awareness. Every child’s dog bite, no matter how small, created dread in parents everywhere. Patients’ agonizing deaths and the helplessness of doctors were regularly reported in the press.

Pasteur’s successful treatment of his first patients grabbed front-page headlines, not just in France, but around the globe, and the coverage continued for months. The biggest splash was in the many competing newspapers in New York City, led by Joseph Pulitzer’s World. In early December, publicity about four children bitten in nearby Newark, NJ, created a fund-raising mania to send them on the next steamer to Paris for treatment. Donors’ names were all printed in the papers, ranging from hundreds given by a New Jersey senator to pennies sent in by school children. The excitement and anticipation was so widespread that cartoonists, humor writers, and editorialists were soon making light of the over-the-top enthusiasm, but not of the treatment itself.

Rabies shots were different from all of a doctor’s other treatments and the cure-alls of the patent medicine trade. Pasteur’s miracle-working injections were make in a laboratory, not a factory, and they were the product of scientific research. This was the first medical breakthrough in world history. It established a revolutionary new concept: the idea of medical progress. Smallpox vaccine had not made headlines, nor had the stethoscope, ether surgery, antisepsis, or the germ theory. But the stories and images of a cure for deadly hydrophobia established a new pattern, which the public came to expect. This shaped the news as well as the responses to discoveries in a never-before-seen series of medical advances like diphtheria antitoxin, vitamins, insulin to cure diabetes, antibiotics, heart transplants and artificial hearts.

There is far more to modern medicine than these headliners, but rabies shots changed the basic expectation of what doctors could offer. In 1885, for the first time in history, a patient was less impressed by a doctor’s degrees or long experience, and more interested in whether he worked in a laboratory and offered the latest results of up-to-date research.

In that moment, people became willing to donate or legislate money for medical research, not just giving charity for hospitals. And quickly the enthusiasm for novelty and utility embedded in the medical breakthrough moved to other sciences too, generating and shaping news coverage for the x-ray, radium, flight, Einstein’s ideas, the atom bomb, DNA, the genome, and all the rest.

Though it may seem improbable that a modest advance among a French chemist’s many discoveries would spark the 20th-century’s excitement about scientific progress, that’s what history tells us.

Jonathan Reinarz

Professor of the History of Medicine and Director of the History of Medicine Unit at the University of Birmingham

I’m tempted to say laughter, but only half kidding when I do so, given the recent campaigns addressing mental illness and loneliness. I think this question would be best answered with an open mind, because we need to switch over to a preventive mode when looking at our greatest health threats in today’s world. So, in line with laughter, good food and clean water are also very much good ‘medicine’. They certainly also tick the ‘variety’ part of your question, as they aid recovery from a number of illnesses, but also help prepare the body to avoid many conditions.

But if you are looking for a ‘medical’ intervention, so an actual medical technology that has been packaged up and sold or provided to the public as a ‘medicine’, you would be hard pressed to beat things such as insulin, saline or blood transfusions. The seat belt might also make that list, as well as the fire extinguisher, helmet and swim vest, given that accidents are taking far fewer lives that they did a hundred years ago. In short, I think we overlook low tech a bit too easily, but that certainly is a result of history and the fact that we find it hard to imagine a world without some of these very useful interventions, which, though not medicines, were often introduced following medical campaigns, or campaigns led by medical practitioners.

David K. Rosner

Professor of History and Sociomedical Sciences at Columbia University

Clean, pure running water. Many infectious diseases—from cholera and typhoid through river blindness and malaria, are directly or indirectly transmitted through polluted or stagnant water supplies. Cholera and typhoid is carried by it, mosquitoes breed in it, etc.

It may sound too “cute” but if you think of clean water as a “medicine” it has undoubtedly saved millions of lives when it is provided to children in poor communities. If you look historically at the transformation in even America’s health you can see that the nineteenth century was marked by a host of infections, some airborne, some due to crowded conditions, some directly transmitted from person to person, or from rat to humans. But, the one intervention that served the entire population and which probably served to undercut the dominance of infections was the introduction of sanitary systems of water distribution and sewerage control. Ultimately, the best “medicine” is the elimination of poverty. After that you can add in vaccines, antibiotics, and other medical technologies.

Alexandre White

Assistant Professor, Sociology, Johns Hopkins University, whose work examines the social effects of infectious epidemic outbreaks in both historical and contemporary settings as well as the global mechanisms that produce responses to outbreak

It sounds trite to say that prevention is the best medicine, but it is so often true. In the late 1970’s it seemed like the fields of medicine and global public health may have solved the problem of infectious disease spread—smallpox had been eradicated, polio was on its way to extinction and the scourges of the past, yellow fever, bubonic plague, measles, mumps and rubella could all either be cured through antibiotics or prevented through vaccines. However, as we were on the cusp of curing or eradicating so many ills that had plagued humanity for so long, we began to discover new threats such as HIV/AIDS, Ebola Virus Disease, Severe Acute Respiratory Syndrome (SARS), and many others that have become global epidemic concerns, causing massive loss of life, and widespread human suffering. While we may not have the cures for HIV/AIDS or Ebola Virus Disease, and many potential cures remain in their experimental and trial phases, interpersonal transmission of tomorrows epidemic emergencies can be prevented today. Condoms, in conjunction with anti-retroviral treatments for HIV/AIDS can all but halt the spread of the disease through sexual transmission if viral loads are undetectable in the HIV person. Vaccines for yellow fever and measles prevent the possibility for transmission of disease by rendering those vaccinated immune to them. Vaccines are especially important to halting the spread of diseases such as measles as they also limit the possibilities of deadly mutations of the pathogens that might make existing medications less effective. This is critical as global measles cases and deaths are on the rise, often affecting the youngest among us.

And finally, while vaccination and prophylactic methods such as informed safe sexual practices and annual flu shots may prevent the reoccurrence of some critical diseases, prevention must also extend to the social and political realm. Events such as the current Ebola virus epidemic in the Democratic Republic of Congo, or the previous West African Ebola epidemic of 2013-2016 are made all the more severe because of ineffective healthcare systems and outbreaks of war, civil strife, and political and economic crises which make the rapid spread of a disease such as Ebola a symptom of wider structural problems as much as a cause of continued suffering. Global climate change, which has both been caused by and has forced agricultural and labor transformations have pushed humans into areas which may expose us to novel pathogens while increased global temperatures will likely see the return of vector borne diseases such as malaria and dengue fever to regions from which they were once eradicated. As conscientious members of the human race and speaking as part of the global health community, we need to be better at recognizing the root social causes of infectious disease spread so that we can better predict prevent the worst epidemics we may see in the future.

Mical Raz

Professor, History, University of Rochester, and the author ofThe Lobotomy Letters: The Making of American Psychosurgery

The best medicine is the medicine that helps the most people at a low cost/high benefit ratio. Accordingly, this would be positive public health interventions which have had an important, measurable benefit on health attainment. Public health initiatives generally cost little and have the potential for huge benefit. Still, there is a lot to be done when American children do not have access to clean drinking water. Historically, the biggest reduction in mortality was a result of 19th century public health interventions, and not of the myriad of innovative medical treatments that were subsequently developed.

Melanie Goan

Associate Professor, Health, Society and Populations History, University of Kentucky, whose research focuses on medical history, among other things

This is a hard question to answer because for every human facing a life-threatening illness or even a chronic condition, the medicine that restores you to health can seem the most important. If I were to identify a specific “best medicine,” Jenner’s small pox vaccine and penicillin come to mind because they led the way to other vaccines and sulfa drugs that have saved countless lives and offered countless cures.

If I step back and define medicine more broadly, I would say that the best medicine has been the discovery of the germ theory. Before the germ theory, developing targeted drugs was impossible because the causes of communicable diseases were shrouded in mystery. Without a sense of disease agents, human attempts at a cure were misguided and appear comical to a modern observer. Shooting cannons to protect people from “bad air” and from contracting cholera during the 1833 epidemic? Seems ridiculous, but without the knowledge that a water-borne bacterium was the culprit, it was impossible to find a solution. After the discovery of germs—and the introduction of sulpha drugs—cures for many terrible killers became available: tuberculosis, typhoid, diphtheria, the list goes on and on.

Stephanie Snow

Senior Research Fellow, Medical Education, University of Manchester, whose research focuses on medicine and healthcare since the nineteenth century.

Human experience of medicine changed irrevocably with the introduction of anesthesia in the late 1840s. Pain free surgical operations and dentistry, and reduced suffering in childbirth were obvious and immediate benefits of breathing chemicals like ether and chloroform. But anesthesia also catalyzed a profound and much broader shift in social and medical attitudes to physical pain. Until the late 1700s pain during surgery was understood to be a stimulant that helped the body tolerate the stress of an operation. And pain during childbirth, chronic disease, and death was an inevitable part of being human. Anesthesia proved that removing surgical pain had no adverse effect on patients and that suffering in childbirth could be eased without harm to mother or baby. By the end of the 1800s it was hailed by doctors and patients as one of the century’s most important discoveries and a definitive mark of a humanitarian and civilized society. It is hard to think of another innovation that has had such a positive and wide-ranging impact, enabling us to benefit from a myriad of medical treatments without suffering pain during the process.

Susan Jones

Professor, Ecology, Evolution and Behavior, University of Minnesota, whose research focuses on the history of biomedical sciences, among other things

The answer depends on whom you ask, and when and where they lived. ‘Medicine’ has encompassed not only drugs, but also prayer and spiritual healing, removing excess bodily fluids to treat a fever (bleeding and purging), and sleeping outdoors at high altitudes to fight tuberculosis. If we consider today “what is the best medicine for the world?” through the lens of decreasing human morbidity (illness) and mortality (death), my answers may surprise you.

The best medicine turns out to be prevention, and that encompasses some pretty low-tech things that we normally classify under ‘public health.’ The best medicines are clean water (especially separating sewage output from drinking and eating intake), enough nutritional food, decent shelter, vaccination, and providing care for the most physiologically challenging conditions of all: pregnancy, childbirth, and the first 5 years of life. My choices are based on the data about the major causes of global morbidity and mortality over the past ten to thirty years,data collected bythe Gates Foundation-funded Global Burden of Disease Study (2010) (1). The data are clear: most morbidity and some 25% of all global deaths are caused by communicable diseases, maternal complications associated with childbearing, neonatal disease and death, and nutritional deficiencies. To be sure, since 1990 the so-called ‘diseases of developed countries’ (chronic diseases and those that have increased because people are living longer) are gaining in importance. Outside of sub-Saharan Africa, non-communicable diseases such as heart and vascular disease were major causes of mortality in 2010. How you are likely to die depends not only on where you live, but how old you are.

The good news is that applying preventive medicines helps with all of these major categories of global mortality. ‘Clean’ water and food means the absence of sewage and carcinogenic or toxic chemicals. Nutritional food would help prevent diabetes and arteriosclerosis in an older person as well as help nourish a toddler. Vaccination has been responsible for major changes in global mortality, even in the mortality of children in developed areas such as the United States. (A walk through a cemetery, with its rows of small headstones for children who died of diphtheria and measles, should be enough to convince us to vaccinate our children today.)

But what about the fantastic technologies we have available now, from antibiotics to CRISPR? Surely one of these medical technologies is the right answer to this question. If we have learned anything in the past century, it’s this: medical technologies (including drugs) make the most difference in morbidity and mortality when combined with an emphasis on preventive medicine. Many will disagree with this conclusion, and this is not a new debate. British physician and epidemiologist Thomas McKeown famously argued against several critics in the 1960s and ‘70s that, “for most diseases, prevention by control of their origins is cheaper, more humane, and more effective than intervention by treatment after they occur.” Although global mortality patterns have been changing since then, McKeown’s analysis has continued to be cogent. We must carefully consider where the money is going and support research and applications of preventive medicine as well as novel medical technologies.

This is not to say that we shouldn’t use or develop medicines and medical technologies. McKeown also wrote: “I do not belong to the small minority of saints, reformed sinners, and others for whom physical discomfort is necessary for mental comfort, and…I should like good medical attention, by whic h Me refiero al servicio clínico que combina la competencia técnica con la atención humana. En efecto. Quizás la pregunta que hay que hacer, entonces, no es “¿cuál es la mejor medicina?”, Sino “¿qué es lo que tiene más impacto?”. Esto debería guiar cómo asignamos nuestros recursos médicos.

Susan Lamb

Profesor Asistente y Jason A. Hannah Presidente de Historia de la Medicina, Departamento de Innovación en educación médica, Universidad de Ottawa

Creo que la mayoría de los historiadores y médicos o científicos probablemente dirían que la mejor medicina es la que podríamos generalizar como Medicina “microscópica” o “celular”. Cuando apareció el microscopio óptico a mediados del siglo XIX, nos permitió ver las bacterias y las células en detalle. Esto llevó a la confirmación de la “teoría de los gérmenes” en la década de 1880 y al entendimiento de que todas las células provienen de otras células y que las bacterias causan enfermedades, ¡que estos pequeños animales microscópicos pueden ser dañinos para nosotros! Y eso permitió a los científicos y médicos identificar exactamente qué microbios causan qué enfermedades, lo que significa que podríamos comenzar a fabricar vacunas, que salvan muchas vidas. También comenzamos a comprender que los microbios causaron infecciones y, por lo tanto, a controlar los microbios que causan infecciones durante la cirugía: esto significaba que los procedimientos quirúrgicos podrían ser más largos y complejos, porque el paciente quirúrgico no entraría en shock séptico una vez que los cirujanos entendieran cómo crear antisépticos quirófanos La teoría de los gérmenes también condujo a la anestesia, que permitió a los cirujanos explorar cirugías aún más complicadas porque el paciente no moriría de shock o dolor mientras se abriera. La medicina microscópica o celular, en otras palabras, facilitó la creación de innumerables intervenciones para salvar vidas, y en 1900 (¡no hace mucho tiempo!) Estábamos salvando vidas de una manera que no habíamos podido hacer en toda la historia humana.

¡Pero todavía tenemos enfermedades contagiosas que no podemos resolver! Podemos identificar las bacterias o los virus, pero no tenemos una vacuna o antídoto efectivo. Entonces, ¿se me ocurre que quizás la “mejor” medicina es simplemente la que funciona? Algunos científicos no querrán escuchar eso, porque hoy queremos que nuestras soluciones vengan con explicaciones científicas. Pero aquí hay un ejemplo.

Un hombre llamado Samuel Pepys pasó diez años llevando un diario detallado a mediados del siglo XVII. Es súper detallado. En sus 20 años, tuvo cálculos en la vejiga, que son increíblemente dolorosos: estamos hablando de ataques de doce horas de dolores realmente severos. Finalmente, decidió que iba a someterse a una cirugía muy arriesgada, llamada litotomía, que se había practicado desde la antigüedad. Encontró al mejor cirujano de Londres, y lo buscó. En una litotomía, se realiza una incisión en el perineo, un área sensible entre el ano y los genitales. No hubo anestesia ni control de infecciones. Te ataron a una silla con las rodillas contra el pecho y probablemente te dieron algo de alcohol para ayudar a adormecer el dolor. Luego, el cirujano corta el perineo y corta la vejiga o masajea el cálculo de la vejiga con el dedo índice y el pulgar. Esto es, recuerde, el siglo XVII, por lo que los instrumentos que están usando no están esterilizados, y el cirujano ni siquiera se molesta en lavarse las manos.

¡Pero Samuel Pepys sobrevivió a esta cirugía! Y está tan agradecido de estar finalmente sin dolor que, por el resto de su vida, celebra una fiesta en el aniversario de su cirugía. Entonces, en todos los sentidos, sabiendo lo que sabemos hoy sobre infección, sepsis, cirugía y anestesia, ¡no debería haber funcionado! Pero funcionó, y Pepys se sintió aliviado de su sufrimiento. Y eso es realmente lo que es la enfermedad: diferentes tipos de sufrimiento. Es por eso que digo que quizás la mejor medicina realmente es la que funciona para el paciente individual.

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Actualización: los comentarios de Susan Lamb se han agregado a este artículo.


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