Book Reviews
Floyd E. Bloom and Mark A. Randolph (Eds.): Funding Health Sciences
Research: A Strategy to Restore Balance.
Washington, DC, National Academy Press, 1990, 255 pp.
The Institute of Medicine (IOM) of the National Academy of Sciences (NAS) recently published the study Funding Health Sciences Research: A Strategy to Restore Balance.
Although the book contains much interesting information about health research funding, the authors never clearly state the problem to be addressed or the possible solution. The book's "Executive Summary" alludes to deteriorating laboratory facilities and expresses concern about the number of trained researchers that will be available in the future, increased research funding for AIDS and the Human Genome Project, and the United States' declining economic competitiveness. From these disparate "disturbing" trends, the members of IOM's Board of Health Sciences Policy apparently concluded that the funding of health sciences research is "out of balance." In particular, the Board concluded that too much of the $10 billion annual medical research budget is devoted to research and not enough to training investigators and refurbishing research facilities. The Board argues that a small percentage of annual research funds should be redirected to training and facilities. In making its case for a shift in funding emphasis from new research grants to training and facilities, the Board debunks some cherished myths of the biomedical research establishment.
Contrary to the claims of both NIH administrators and leading bench scientists, there is no crisis in research funding: the IOM report indicates that biomedical research is more lavishly endowed today than at any other time in the nation's history. The real problem, never directly addressed by the IOM study, is the burgeoning number of Ph.D. bench scientists who compete for NIH grants every year. Several of NAS' own personnel studies for biomedical and behavioral research have documented the precipitous rise in the number of bench scientists and the proportionate decline in the number of M.D. clinical investigators. The IOM Board's repeated prediction of an across-the-board shortfall in biomedical research personnel is never supported with evidence. Given current trends, it would be difficult to make the case that there will be too few bench scientists available in the foreseeable future. The IOM Board makes a more convincing case for the existence of a crisis in clinical investigation: the decline in M.D. researchers has been apparent in all of the NAS personnel studies since the late 1970s and is now well known. (It is also well known that the crisis in clinical investigation is a direct result of the Nixon Administration's "payback policy" -- the decision to require all NIH-trained post-doctoral clinical fellows to pay NIH back.) Clinical investigator Dr. Samuel Their, Director of IOM when the study was released, has himself repeatedly decried the decline in trained clinical investigators in the United States.
In all likelihood, Dr. Thier was the primary motivating force behind publication of Funding Health Sciences Research. While Their has never explicitly addressed the issue of imbalanced U.S. biomedical research funding in an American journal, he has clearly expressed his views in the British Medical Journal (BMJ). The November 5, 1988 issue of the journal covered a Royal Society meeting on the funding of science at which Their spoke about biomedical research funding. Under the heading "Threats to Research," the BMJ reporter wrote:
The balance of medical research in the United States is under threat, said Dr. Samuel Their, president of the Institute of Medicine. Basic research, clinical research, and public health research should be balanced:.. . the importance of basic research is overemphasized.
At the meeting, Their reportedly called the notion that advances in clinical practice grow out of basic laboratory science "a myth." Their's advocacy of clinical science helps explain why the IOM study repeatedly stresses the decline of the physician investigator. In the chapter "Nurturing Scientific Talent," the report states: "Particularly alarming is the apparent decline in the number of physicians engaged in health-related research." In 1988 IOM had conducted a study called Resources for Clinical Investigation, which highlighted the crisis but made no specific recommendations for ameliorating the imbalance in research funding. In contrast, the present volume begins to offer specific solutions. The study's principal recommendation is that NIH shift about 2 percent of its research budget to training.
According to the October 5, 1990 issue of Science, the proposal to shift funds from research to training was so controversial at IOM that an internal review panel had rejected an earlier draft of the report. The meager 2 percent figure is apparently all the IOM committee could get past internal review. Even that amount was enough to outrage the president of the Federation of American Societies for Experimental Biology (FASEB), the laboratory research lobby. Dr. Thomas Edgington reportedly accused IOM of trying to prevent life-saving research by "placing too much emphasis on infrastructure and training and too little on the plight of individual researchers seeking grants" (Science, November 30, 1990). In defending the report, Their explicitly raised the issue of FASEB's bias against patient-centered investigations. According to Science (December 7, 1990):
Their was particularly upset that Edgington . . . accused IOM of stacking its panel with university administrators anxious to solve their financial problems at the expense of individual scientists. Their reported in an interview. . . that more than half of the 18 panelists were working scientists, and he accused FASEB of failing to recognize that epidemiologists and sociologists are scientists, too.
Congress nonetheless ignored IOM's recommendations in 1991.
The book's principal value, then, seems to have been in evoking such a strong reaction from the scientific community. This reaction clarified that the pro-laboratory/pro-vivisection lobby is more concerned about the special interests of working laboratory scientists than about public health science and public health. An additional lesson of the book's aftermath is that the pro-vivisection lobby's attitude toward the animal rights/welfare movement is by no means a unique phenomenon. FASEB attacked IOM's president with the same venom it directs at the animal movement. In the quest for more laboratory research dollars, it would seem that nothing and no one is sacred.
Brandon P. Reines
Sherwin B. Nuland: Doctors: The Biography of Medicine.
New York, Alfred E. Knopf 1988, 519 pp.
A Yale surgeon, medical historian, and longstanding editor of the two leading journals of medical history, Sherwin Nuland has gained increasing renown since the 1988 publication of his book Doctors: The Biography of Medicine. Nevertheless, the book lacks both substance and objectivity.
Instead of offering genuine insight, Nuland offers drama and polemic. He chronicles 10 of the 12 physicians included in Henry Sigerist's classic The Great Doctors. However, whereas Sigerist presented straightforward biography, Nuland uses the biographical mode as a way of advancing his well-publicized pro-vivisection stance. Just as Nuland idealized vivisection and caricatured its opponents in a 1989 Op-ed piece syndicated in a number of major newspapers, so he resorts to exaggeration and distortion in Doctors. He does manage to create detailed portraits -- even for subjects such as Harvey, about whom little biographical information is generally available, All figures, though, are judged by their adherence (or lack of adherence) to the method of laboratory experimentation. To the extent that they practiced this method, subjects are glorified; to the extent that they did not, they are belittled. For this reason, Nuland's portrayals often border on caricature.
It is remarkable, for example, that Nuland is still able to regard John Hunter as the 18th century's primary hero of scientific medicine and surgery. In a 1948 paper in the Bulletin for the History of Medicine, Lloyd Stevenson demonstrated that Hunter's most famous animal experiment -- on the stag of Richmond Park -- probably never took place. Yet, Nuland perpetuates the view, first advanced in 1876 by Sir James Paget, that this alleged experiment led to the discovery of the principle of collateral circulation. No historical evidence supports that view; abundant evidence contradicts it and indicates that the discovery arose, instead, from clinical observation. Nuland seems unaware that most modern scholars consider John Hunter's renown to have derived primarily from his role in improving surgeons' public image, rather than any refinement of scientific method or particular discovery, It was, in fact, John's brother, William, who was the expert on circulation anomalies. Unfortunately, because William lacked his brother's experimental and surgical bravado, his work has rarely been highlighted by historians,
The counterpoint to Nuland's glorification of John Hunter is his disparagement of the 19th century physician Ignaz Semmelweis. Nuland claims that Semmelweis' famous studies of women with childbed fever did not lead to the germ theory of disease because Semmelweis did not experiment enough. Nuland states that Semmelweis "never did the experiments that might have helped his cause, nor was he able to convince any of the then increasing number of skilled laboratory researchers that his ideas were worth investigating." Once again, Nuland's yardstick is the extent to which the biographical subject conducted and spawned laboratory research -- as if Semmelweis' clinical work were somehow less valid or legitimate. To the contrary, Semmelweis' espousal of "one single necessary cause" of childbed fever seems to have grown out of his clinical investigations. Laboratory studies could not have demonstrated the actual causes of the disease in the real world, K. Codell Carter, the pre-eminent American Semmelweis scholar, has persuasively argued that Semmelweis' ideas were adopted by his successors and did lead to the germ theory, in the hands of Mayerhoef, Pasteur, and Koch. Although Nuland cites Carter's translation of Semmelweis' original work on childbed fever, he ignores Carter's biographical assessment of Semmelweis.
Nuland rarely bothers to reappraise his subjects' medical contributions on the basis of modern scholarship, either historical or philosophical. For example, he ignores works such as Thomas Kuhn's seminal The Structure of Scientific Revolutions, which discusses the fact that no method of scientific inquiry is free of human subjectivity or the pressure, exerted by the scientific community, to interpret data from the perspective that is currently the status quo. Nuland simplistically portrays scientific truth as some absolute with only one correct method of approach -- inductive laboratory investigation. His heroes, in turn, are unbiased pursuers of this truth. Nuland, for instance, romanticizes Harvey with this 1906 quotation from Sir William Osler: "here for the first time a great physiological problem was approached from the experimental side by a man with a modern scientific mind, who could weigh evidence and not go beyond it." As soon as one interprets evidence, one goes beyond it.
In Doctors, Nuland perpetuates popular myths of what does and does not constitute genuine science. The book contains gross inaccuracies and a lack of any but the most unquestioningly traditional perspective. Yet, reviews in ISIS and the Bulletin for the History of Medicine have contained only the mildest criticisms. Clearly, some reviewers are reluctant to criticize a prominent member of the reigning medical fraternity. With Doctors, the American public has lost an opportunity to learn about the actual method and achievements of history’'s leading physicians.
Brandon P. Reines, D.V.M.
Hans Ruesch: 1000 Doctors (and Many More) Against Vivisection.
CIVIS, Swam, NY, 1989, 281 pp.
Medical historian Hans Ruesch shows that, during the past century, over 1 ,000 physicians, veterinarians, and Ph.D.'s have objected to animal experimentation. Providing an impressive collection of names and quotations, Ruesch illustrates that it is neither new nor rare for medical experts to criticize animal research.
Ruesch quotes numerous members of the scientific community and provides some of their biographies at the end. Here are just a few of the many memorable quotations offered:
Like every member of my profession, I was brought up in the belief that almost every important fact in physiology had been obtained by vivisection and that many of our most valued means of saving life and diminishing suffering had resulted from experiments on the lower animals. I now know that nothing of the sort is true concerning the art of surgery: and not only do I not believe that vivisection has helped the surgeon one bit, but I know that it has often led him astray.
Lawson Tate, M.D. (1884)
It is not true that we owe knowledge of drugs to experiments upon animals. The effect of drugs upon animals is so entirely different from their effect upon man that no safe conclusions can be drawn from such investigations. It is not true that Von Graefe discovered a cure for glaucoma by vivisection; his discovery was entirely the result of clinical observation of hospital patients. Vivisection had nothing whatever to do with it. And it is not true, notwithstanding assertions to the contrary, that Ferrier has succeeded in localizing the functions of the brain by experiments on monkeys. Ferrier himself says: 'Experiments on animals, even on apes, often lead to conclusions seriously at variance with the well-established facts of clinical and pathological observation.'
We are assured that it is impossible for science to advance unless experiments are made upon animals, but this statement is not true.
Charles Bell Taylor, M.D. (1895)
My efforts to head off the poisoning of hundreds of women with breast cancer with a dangerous drug that could destroy their host defense systems failed. The National Cancer Institute went right ahead. Now a few women with breast cancer have paid with their lives for this stupidity. The moral is that animal model systems not only kill animals, they also kill humans.
Irwin D.J. Bross, Ph.D. (1983)
'[A]nimal model systems' in cancer research have been a total failure.
For instance, not a single essential new drug for the treatment of human cancer was first picked up by an animal model system. All of the drugs in wide current clinical use were only put into animal models systems after finding clinical clues to their chemotherapeutic possibilities.
Irwin D.J. Bross, Ph.D. (1982)
Despite the forcefulness of many quotations, two principal weaknesses diminish this anthology's potential impact. First, many of the "doctors against vivisection" are not necessarily opposed to all vivisection. They voice concerns only about specific animal models or merely cite particular instances in which animal research has not benefitted human health. A few are even career animal experimenters, such as Harry F. Harlow and Robert Koch.
Second, Ruesch offhandedly dismisses those who disagree with him: "All those who assign validity to the animal model system are people who derive a morbid satisfaction or a monetary gain from it," he states. Similarly, he gratuitously comments, "Particularly damaging to the abolitionist cause are the 'animal rights' organizations -- lately ballyhooed by the press -- who are either headed by incompetent people, however honest they be, or have been taken over by the industrial interests, or else have been founded by them outright."
Although marred by such overgeneralizations, 1000 doctors makes it powerfully clear that opposition to animal experimentation on scientific and medical grounds has been and remains a widespread phenomenon, despite animal researchers' claims to the contrary.
Stephen R. Kaufman, M.D.
Pietro Croce: Vivisection or Science: A Choice to Make.
CIVIS, Rome, 1991, 230 pp.
From 1952 to 1982, physician Pietro Croce headed the laboratory of microbiological-pathological anatomy and chemo-clinical analyses at the research Hospital L. Sacco in Milan, Italy. A leading European critic of animal experimentation, Croce argues in Vivisection or Science that animal experimentation purportedly aimed at illuminating human disease processes is, in actuality, the study of artificially induced pathology in non-human animals in an unnatural (and stressful) laboratory setting. Consequently, animal "models" are, at best, poor analogues of human disease. While analogies are often dramatic, they are not scientific. Furthermore, he observes, the "validity" of particular animal data can only be judged post hoc, after human data becomes available. Therefore, animal experiments are not a means of discovery.
Croce also points out that toxicology studies using non-human animals are unreliable. Animal tests of carcinogenicity and teratogenicity, for example, are notoriously unpredictive of human sensitivity. In fact, toxicology tests using animals are frequently dangerously misleading. Morphine excites cats but relaxes humans. Penicillin kills guinea pigs by altering intestinal flora but has no such effect on humans. Digitalis does not raise blood pressure in humans; yet, its use to treat human cardiopathies was delayed for years because it raises blood pressure in dogs.
Croce discusses in detail possible new applications of non-animal research methods, including computer analysis, in vitro tests, and human clinical trials. He stresses that such methods are generally superior to animal studies and should not be called "alternatives." For example, in vitro systems have demonstrated self-limitation of tissue growth and the fragility of links between cancerous cells. Croce, however, does not adequately address the methods' limitations. In vitro models, like animal models of human diseases, tend to be very reductionistic; research results may reflect attributes of the in vitro system that do not exist in intact human beings.
Unfortunately, the book frequently jumps from one observation to another without drawing a connection. Given the book's loose organization, it would have been helpful to include an index. Dr. Robert Sharpe's The Cruel Deception is easier to read and Dr. Andrew Rowan's Of Mice, Models & Men is better documented. Nevertheless, Vivisection or Science makes important contributions in its critique of animal modelling and its discussion of non-animal methods.
Stephen R. Kaufman, M.D.
Nina Natelson and Murry Cohen (Eds.): Future Medical Research Without the Use of Animals: Facing the Challenge
Concern for Helping Animals in Israel, Washington, D.C., 1991, 180 pp. $12.95.
In May 1990, many prominent critics of animal experimentation met in Israel to present their perspectives and exchange ideas at the "First International Medical Conference" on animal experimentation. The proceedings are now available in print.
Attorney Gary Francione provides an introduction that addresses growing ethical and scientific concerns about animal experimentation and how changing laws reflect these concerns. Among the conference highlights, an essay by physician Henry Heimlich details his long and successful research career based on human clinical observation, not animal experimentation. Psychiatrist Murry Cohen discusses the scientific fallacies of using nonhuman animals to investigate human psychology. Medical historian Brandon Reines offers an overview of his research, which has led him to conclude that the major medical discoveries have been based on human clinical observation. In another thought-provoking contribution, statistician Irwin Bross shares evidence that animal testing has involved the use of fraudulent statistical methods to "demonstrate" the safety of dangerous mutagens. Toxicologists Erik Walum and Canton Nadolney review the potential applications of alternatives to animals in testing protocols. Through an autobiographical account of redundant radiation studies on monkeys, psychologist Don Barnes illustrates how individual animal research projects can continue, for years, because of inertia. Veterinary ophthalmologist Nedim Buyukmihci and physician Stephen Kaufman critique animal models of amblyopia and of multiple sclerosis, respectively.
Most of the papers are informative and insightful. Unfortunately, overgeneralizations mar those by pharmacologist Noemi Pascal (on the reasons that animal experimentation continues), physician Pietro Croce (on animal research's basic conceptual flaw), and physician Peter Mansfield (on holistic medicine).
The helpful question-and-answer sections that follow most papers address comments from the conference's skeptical audience, which included many proponents of animal experimentation.
Readers interested in a critical examination of animal experimentation will find this book valuable.
Stephen R. Kaufman, M.D.