Medical Milestones

I've got a little list

BMJ 2007; 334 doi: (Published 04 January 2007) Cite this as: BMJ 2007;334:s20
  1. Jeffrey P Koplan, vice president for academic health affairs
  1. 1Woodruff Health Sciences Center, Emory University, Atlanta, Georgia

    We all enjoy top 10 lists or other numerical variants, be they selections of riverside pubs, classic rock guitarists or neurosurgeons, the world's best beaches, or the Mann-Booker shortlist. Such lists allow us to focus our own views and congratulate ourselves for our good taste or astute judgment: “The list seems valid, as they chose Mark Knopfler, Jeff Beck, and Eddie Van Halen.” They also permit us to scoff at the ignorance or lack of taste of the compilers: “Where are Joe Perry, Dickie Betts, and Stephen Stills?” But I digress.

    Rarely do these lists have the explicit quantitative criteria that would satisfy a Cochrane collaborator. But the fun—and frustration—is in the subjectivity of the choices. If readers find themselves in agreement with over half the list then some modicum of satisfaction is achieved. Thus all BMJ readers will have turned, with a sense of anticipation mixed with scepticism, to the list in this supplement of the top 15 (egregious inflation of the more decimally traditional 10 or the more familiar dozen) medical milestones of the past 166 years. The list was developed by inviting nominations from readers, and then a final selection was made by a panel of experts—a quasi-democratic cum oligarchic process that is highly likely to lead to an untidy outcome. Unlike pubs, guitarists, or novelists, a medical milestone may mean quite different things to different people. It certainly would include leaps forward in diagnosis and treatment, but it also permits the inclusion of methodological or experimental advances that are far upstream from their bedside application. The impact in numbers of lives saved or diseases averted or controlled could be a factor in identifying a milestone but is not so clearly stated or universally accepted.

    Let's look at the BMJ's top 15. In the diagnostic category we find imaging. Several therapeutic advances are listed: anaesthesia, antibiotics, oral rehydration therapy, and chlorpromazine. Now we move across the menu to items that can be lumped into preventive measures (the pill, vaccines, sanitation), theories (the germ theory), technology (computers), basic scientific discoveries (the structure of DNA), epidemiological discoveries (risks of smoking), approaches to medical science (evidence based medicine), major disciplines of bioscience (immunology), and a laboratory technique (tissue culture). This is a most interesting and varied group of milestones, certain to stir debate and elicit reflection. One common feature of all these milestones is that their existence and significance were likely unforeseen when the BMJ was established in 1840, but they have all had a major effect on the length and quality of life.

    I'll admit to some bias. In 1999-2000 I initiated, at the US Centers for Disease Control and Prevention (CDC), a top 10 list of public health achievements of the 20th century in the United States.1 Although this exercise was specific to the US, other high income countries have had similar achievements. A considerable overlap exists between the CDC's list and the BMJ's final 15 milestones: half the items on the CDC list (effective and reliable birth control, antibiotics, vaccines, recognition of the risks of tobacco and the institution of effective tobacco control programmes, and water and sanitation) are also represented on the BMJ list. But the missing five items merit discussion here: improving safety and reducing hazards in the workplace; providing safe and nutritionally enriched foods; preventing motor vehicle injuries and deaths; improving oral hygiene; and recognising the risks for coronary heart disease and instituting actions to reduce morbidity and mortality from the disease. All these items have had a major and direct effect on quality of life. For example, more and healthier teeth permit a more varied and enjoyable diet and better nutrition; healthier diets and fortified food have eliminated micronutrient disorders such as rickets, goitre, pellagra, and iron deficiency from large populations across the globe. And the five items have reduced the number of preventable deaths and injuries: the number of injuries sustained by miners, railway workers, and factory workers fell by 90% in the US from 1933 to 1997; rigorous governmental standards have reduced exposure to toxic substances in most industries; mortality from motor vehicle collisions has fallen, thanks to safety equipment, better highway design, education, and a reduction in associated risk factors such as alcohol use; and millions of life years have been saved through large reductions in the prevalence of smoking in many countries. (A new book, Silent Victories, describes these achievements.2)

    These two lists encourage a discussion of the relative contributions of biomedical science and public health. Biomedical science has won more Nobel prizes, while public health has had a greater role in reducing morbidity and mortality and improving our quality of life. Of course, each approach contributes to the other. We need to develop safe and effective vaccines for serious illnesses; and we need to be able to deliver these vaccines to people at risk. Similarly, even as we develop an understanding of the human genome, we must make this knowledge practically useful and economically feasible and must ensure that benefits of research are distributed equitably and ethically.

    So, peruse the BMJ's top 15 milestones, consider the pipeline of discovery and experience that led to them, and imagine their future evolution. In another 166 years, which of the items in the list will still be considered milestones? The current list is interesting and provocative but, of necessity in such lists, incomplete. So, where's Eric Clapton?


    • Publication of this online supplement is made possible by an educational grant from AstraZeneca

    • Competing interests: None declared.


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