Biomedicine Eyes 2020

John Watson, National Institutes of Health

I will present ideas from my experience with targeted, goal-oriented research programs and traditional investigator-initiated research projects. I strongly endorse both approaches. For NBIC to reach its potential, national science and engineering priorities should be set to complement investigator-initiated research projects. We should consider including in our NBIC thinking "human performance and health" (not just performance alone) to provide the most for our future quality of life.

How many of us know someone who has undergone angioplasty? A vision for ten and twenty years is under consideration: tomorrow's needs, tomorrow's patients, and tomorrow's diverse society. Well, what about today's needs, today's patients, and today's diverse society? It is riskier to talk about targeting a research goal to solve today's problems than to focus on promising basic research for solving as yet undefined problems.

We do not know what causes atherosclerosis. Surgically bypassing atherosclerotic plaques was shown to have clinical benefit. Using a small balloon to push the plaques into a coronary artery wall, thus opening the lumen, was met with lots of skepticism. If we had waited until we knew all the atherosclerosis basic science, millions of patients would not have benefited from angioplasty.

Picking up on Newt Gingrich's comments about providing some constructive unreasonableness to the conversation, let me suggest expanding our thinking to science and engineering, not science alone. Also, one can compliment our executive branch and Congress for setting national priorities. For discussion today, I will use the example of Congress establishing as a national priority use of mechanical systems to treat heart failure.

If NBIC is to blend into the fifth harmonic envisioned by Newt Gingrich, some national priorities are needed to complement unplanned, revolutionary discoveries. For instance, urinary incontinence a major health problem for today's patients. If the nation had a science and engineering capacity focused on urinary incontinence, this very personal problem would be virtually eliminated. As Mr. Gingrich stated, basic research can be associated with a specific goal.

Table A.1 is a list of the greatest engineering achievements of the past century. The primary selection criterion in constructing this list was worldwide impact on quality of life. Electrification was the number one selection, because the field was fully engineered to improve efficiency, lower cost, and provide benefit for virtually everyone. You will notice that healthcare technologies is number sixteen. NBIC technologies could focus on this field in this century and help move it into the top ten, to the enormous benefit of human performance, health, and overall quality of life.

Setting priorities involves national needs, process, and goals. The Congressional legislative process is quite effective for targeting priorities. The human genome is an example of a work in progress. Today I would like to focus on the field of prevention and repair of coronary heart disease (CHD), where the clinical benefits timeline for today's patients is a little clearer. Successfully addressing priorities such as these usually requires a few decades of sustained public (tax payer) support.

Table A.1. Greatest Engineering Achievements of the Twentieth Century

1. Electrification

11. Highways

2. Automobile

12. Spacecraft

3. Airplane

13. Internet

4. Water Supply

14. Imaging

5. Electronics

15. Household Appliances

6. Radio and TV

16. Health Technologies

7. Agricultural Mechanization

17. Petroleum Technologies

8. Computers

18. Laser and Fiber Optics

9. Telephones

19. Nuclear Technologies

10. Air Conditioning & Refrigeration

20. High-performance Materials

Following hearings in the 1960s, Congress identified advanced heart failure as a growing public health concern needing new diagnostic and treatment strategies. It called for NIH to establish the Artificial Heart Program. Following a decade of system component research, the National Heart, Lung, and Blood Institute (NHLBI) initiated the left ventricular assist device (LVAD) program in 1977. Research and development was targeted towards an implantable system with demonstrated two-year reliability that improved patients' heart function and maintained or improved their quality of life. A series of research phases based on interim progress reviews was planned over a fifteen-year timeline.

A few years earlier, the NHLBI established less invasive imaging of coronary artery disease as a top priority. A similar program was established that produced less invasive, high-resolution ultrasound, MRI, and CAT scanning for evaluating cardiac function and assessing obstructive coronary artery disease. While this was not an intended outcome, these imaging systems virtually eliminated the need for exploratory surgery. The purpose of long timelines for national programs is not to exclude individual or group-initiated research, and both can have tremendous benefit when properly nurtured.

Figure A.4. NHLBI program organization.

Heart failure remains a public health issue. At any given time, about 4.7 million Americans have a diagnosed condition of this kind, and 250,000 die each year. The death rates and total deaths from cardiovascular disease have declined for several decades (Fig. A.5). However, during this same time frame, death rates from congestive heart failure (CHF) increased for men and women of all races (Fig. A.6). The most recent interim look at this field estimates that 50,000 to 100,000 patients per year could benefit from left ventricular assist (90% of the patients) and total artificial heart systems (10% of the patients), as reported by the Institute of Medicine in The Artificial Heart (1991).

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