by C. Everett Koop

March 28, 1996

I am delighted to be with you today, to have a few minutes to share with you some of my thoughts -- and even a few recollections -- of the role of medicines in the practice of medicine, in the science and art of healing.

This is an unusual speaking opportunity for me. As most of you know, since the day I left my post as your Surgeon General, I have devoted myself to the challenge of health care reform in the United States. During the last seven years, I have criss-crossed this nation many times, speaking out on the ethical imperative for health care reform, and offering concrete suggestions about what we need to do. I must admit I was disappointed by the inability of the President and the Congress and the American people to come to agreement on health care reform, disappointed, but not surprised. After a lot of high expectations generated by the Clinton Administration and others, the great health care reform juggernaut came to naught. So, this slow pace is nothing new.

I remember discussing the need for health care reform several years ago with that fine old gentleman, Claude Pepper, who really was the senior spokesman for all of us who shared concerns about our health care system even back then. A very elderly man, closer to 100 than most of us will ever get, Claude Pepper would often say that he was sure that we would eventually get health care reform, but not in his lifetime. After he died, I've been told, Mr. Pepper went to heaven, and the first thing he asked God was if there would ever be health care reform in the United States. I understand that God replied, "Yes, there will be . . . but not in my lifetime!"

We face sweeping changes, not all of them good. We face great challenges, not all of them bad. As Congress and the country have now learned, when it comes to all the problems associated with health care reform, there is no panacea, no single magic bullet; there are no easy answers, only hard choices. That is because Americans have three demands for our health care: (1) immediate access to health care, (2) the latest high-tech medicine, and (3) a limited price. But now these three demands have become incompatible. We can usually supply any two of them, but it may be impossible to have all three. That is not a very pleasant diagnosis for our health care system, and not a very easy prognosis. That is why I say that this speaking opportunity is unusual for me. Instead of playing the role of stern diagnostician for the nation's health care system at the present, I will enjoy a time of celebration of what we have accomplished in the past, so we can take some cheer and confidence for the future.

A gathering like ours today is critical. We must be able to place the discovery and development of new medicines into a context that is worthwhile for both the health care professional and the public. As we go through the process of reforming our health care system -- and, even though there was no legislative reform, the system is reforming itself, even as I speak -- as we reform our health care system, we need to keep foremost in our mind the role that medicines play in medicine.

The earliest written documents of medical history, Egyptian papyri 4000 years old tell us of poppy seeds as a treatment for flatulence and iron as a treatment for baldness. As a glance at one evening's worth of television will show, we are still offering remedies -- not cures -- for these two ancient human afflictions. (From what I know of Egyptian art, all those images of bald pharaohs might indicate the severity of their problem!)

Closer to home, in our own history, we see the importance the first colonial physicians placed upon the drugs they extracted from the plants found in the new world. In their mainly theological view of the world, they fully expected God to provide in each part of the world the natural plants needed to combat the illness of that part of the world. And while our world view may have become more secular, today many of us have faith in our god-given powers of discovery and intellect to derive what we need from the laboratory as well as from the natural world around us. But the complexities and mysteries of the modern scientific derivation of medicines can produce misconceptions about medicines among the public, and even among health practitioners.

This symposium, and the exhibition Medicines: The Inside Story -- by addressing the history of therapeutics, by presenting case studies of drug discovery, by exploring the disciplines of medicine making, and by explaining how medicines of from market to patient -- by these methods this symposium will indeed tell the inside story about medicines, a story that should be better known by all.

Although there are mornings that I feel old enough to have been around since the time of the pharaohs, I'm not quite that old. But, I am older than most people currently at work in our health care system and in health care industries. Actually I guess I could just say that I am older than most people, . . . period!!

My grandchildren frequently ask me questions like "did they have telephones when you were a boy?" or if there were trains when I was a little boy, or maybe even if I remembered the invention of the wheel. But my recollections of medicine and medicines do go back far enough to be appropriate to the subject of this conference.

When I was a college student on summer vacation, I worked in a small 50-bed hospital on Long Island, starting out doing scut-work, working my way up to doing blood counts and helping in autopsies, cutting thousands of sections on the microtome, and eventually catching the eye of the chief surgeon of the hospital, who also served as chief surgeon at a nearby 300-bed hospital for crippled children. This was in the days before sulfanilamide and before antibiotics. He took me under his wing, and gave me a rare experience.

There were only four diagnoses in that hospital:

• Congenital defects of orthopedic nature,
• Aftermath of polio,
• Tuberculosis of the bone, and
• Osteomyelitis.

One of my chores was to change all dressings on osteomyelitis patients, once a week. Some of these wounds stretched from ankle to hip, with bones exposed. It took me from 8 am Monday morning until 5 pm Friday afternoon to change all the dressings in the hospital; we really had very little to help these young patients. In the summer, the children were put outside in their purulent dressings. Often, when I uncovered the wound, I would find maggots in it. But that was good, because maggots ate away the decayed flesh, actually helping the patient by cleansing the wound. So we raised more maggots, by catching flies in a jar with a cover and a cheese cloth stretched halfway down, so the eggs would drop through the cloth, and we'd extract the maggots, and use them therapeutically.

The only medication I had was balsam of Peru. I would soak strips of gauze in that nice smelling but sticky compound, pack the wound and apply the dressings. In my senior year in college, a new drug appeared, called Pontalin, brand name for the first sulfanilamide. The nurses knew it was good for infections, and even worked against streptococcus, but they didn't know it required a steady dosage over a period of days, and used it like aspirin. There are very few physicians today who have had experience before sulfanilamides, so I am a rare bird.

Later, as a surgical resident at the University of Pennsylvania, I was the custodian for the entire city of Philadelphia for the new drug, Penicillin. I doled it out to sick patients on the pleas of their physicians, between five and seven every afternoon. Even for the worst infection, we never gave any patient more than 100,000 units a day.

But my most poignant recollections of the differences that modern medicines can make are the recollections, not of a physician, but of a parent and grandparent. I never lost the sense of wonder when I saw a youngster's fever and infection controlled by an antibiotic. I will never forget my first walk through a colonial New England cemetery, where tiny gravestones mark the many young children "carried away by fever." In the world of medicines, these are the good old days. And now, I'd like to make a few remarks that will anticipate what follows in the symposium today and tomorrow.

This story that will unfold will be one of tradition, serendipity, systematic research, and compassion. A context will be provided for not only an historical understanding of the past and present, but also for the future of medicines.

This has been a century of great achievements in therapeutics -- vaccines, hormones, antibiotics, analgesics, antihypertensives, antipsychotics, vitamins, and antineoplastics -- among a host of new agents. To many people, these have all appeared to arise from nowhere, to be added to the armamentarium with ease. Like the drugs of old, however, this is not the case. One misconception is that the medicines of ancient times were all useless and inert. Instead, recent research has revealed that our ancestors had a sophisticated understanding of plant drugs and their utility. Although scores of drugs were carried along by tradition only, they were all placed within a Hippocratic and Galenic context that was shared by healers throughout the western world for centuries. The Greek Herbal of Dioscorides, from the first century A.D., provides hundreds of plant, animal, and mineral remedies for illness, and was used by European physicians for the next 1500 years.

Further advances came during the Middle Ages, when Arabic chemists discovered and cataloged many substances in the process of their search for a substance that would transform metal into gold . . . not the last instance of medicines being discovered by serendipity. Also during the Middle Ages, physicians used opium and alcohol as pain relievers, and employed a variety of emetics.

While the Renaissance brought great advances in anatomy -- especially the work of Vesalius -- the next great changes in medicines came in the eighteenth century, as Jenner began his work with inoculation and vaccination. New drugs upset old theories that had become fossilized, especially as scientists began the pharmaceutical assault upon micro-organisms.

By the 1800s, a greater understanding of the human body and its processes, the work of Pasteur and others, plus the concurrent development of scientific chemistry, set the stage for the modern era of drug exploration.

I greatly look forward to this afternoon's session when a group of historians will look at the modern process of drug discovery in more detail. Before the twentieth century, drugs either came from antiquity (such as opium), out of folk traditions (like digitalis), or were found by chance. Beginning in the late 1800s, men like Paul Ehrlich pioneered the scientific exploration for new drugs. Chance findings still yielded great results, as with penicillin, but as our century progressed, more drugs came out of well-organized research projects, typified by the efforts of scientists who worked on the sulfa drugs.

As we will learn as well from the insulin story, research is a human activity, fraught with egos and frailties. In the early 1800s, physicians and pharmacists alike acquired their knowledge of medicines in classes taught by professors of chemistry and materia medica. The roots of the modern sciences of medicine making can be traced to that time.

Tomorrow we will hear about some of the key disciplines of medicine making, what progress has been made during the recent past and where they are heading. These are exciting times. In medicinal chemistry, new technological developments are changing how drugs are discovered. In pharmacology, the explosive growth of the biological sciences has changed the disciplinary landscape. Pharmacognosy, the direct descendent of the old discipline of materia medica, is now in a renaissance, inspired by a combination of interest in folkloric knowledge about drugs and a widespread desire for milder, more "natural" medicines. And in pharmaceutics, the usually quiet science of drug delivery systems, new dosage forms hold significant promise for greatly improved medicine use with reduced side effects.

And yet, even with safe and well-designed medicines, problems loom on the horizon. During the final session of this symposium, some of the most difficult and important issues facing the future of medicines will be addressed: change is coming in the health care sphere, primarily in the area of managed care, which threatens to stifle drug discovery and development by removing essential incentives. The present system of regulation, which has made our medicines the safest in the world, is under scrutiny by congressional leaders who believe that less regulation is better for our nation.

The marketing of pharmaceuticals, which had been clearly different for prescription drugs and over-the-counter remedies, is now growing murky. The inter-professional relationships of physicians and pharmacists are being strained under the often contradictory pressures of consumerism, professionalism, and benefits management.

And finally, we must remember to look beyond our shores and consider the health of the world's community and how our work in health care research can benefit humanity as a whole.

Before concluding, I would like to suggest a few questions for discussion as the symposium progresses:

• In what areas of health have medicines had their greatest impact? And in what areas of health have they seemed to fail?
• Do the chronic diseases of the industrialized West attract more research attention than the acute illnesses afflicting much of the developing world?
• Are there limits to what medicines can do in theory, and if so, what are they?
• Are present health practitioners doing an adequate job to assure the proper use of medicines, and if not, what can they do to improve matters?
• What is the long-term future for medicines research in the United States and what can be done to improve its prospects?

I am honored to have been asked to take part in your symposium. I share your sense of pride in what medicines have done for humanity. I share your enthusiasm for what they can still do in the future. But we all also share a sense of human limitations.

I went into medicine for the same reason that folks pursue the discovery of medicines: to prolong life and to alleviate suffering. We have done a lot of both, but there comes a time when we reach our limits. There comes a time when life can no longer be prolonged, when suffering is inevitable. . . .We need to remember this. We need to remember what health care really means. We need to understand our limitations as well as our aspirations.

As I have said "health care" so often in the last minutes, how many of you translated that to healthcure? We put too much emphasis on curing, too little on caring. We need to do more about the times we cannot provide the cure, but still can provide the care. Curing can cost billions, while caring comes from the heart and soul, and is always ethical. Sometimes, when dealing with complex issues of curing and caring, with the role of medicine -- and medicines -- in society, the place of healing in life, the meaning of life itself, . . . sometimes an anecdote sums things up just right. This one has to do with a couple who died and went to heaven, and when they got there, as you might expect, they found things to be superb. One day, they were sitting together, and the man said to his wife, "We should not be surprised about how wonderful things are here. Do you remember what the minister told us? Do you remember that the Bible said that the 'eye has not seen, nor has ear heard the wonders that God has prepared for those that love Him,' and look around you, is there anything upon which you could improve?"

He paused and added, rather pointedly, "you know, we could have been here three years ago if you hadn't discovered non-fat food!"

But, not to be dismayed, she said, "Three years ago! We could have been five years ago if you had only stopped listening to those health messages from C. Everett Koop!"

Thank you.