HAEMATOLOGY IN THE NEW MILLENNIUM

摘要

As haematology enters the new millennium, like the rest of medical practice it takes with it a rather uncertain inheritance from the second half of the twentieth century. In summing up the current medical scene recently, the historian Roy Porter has written: ‘Today, with “mission accomplished”, its triumphs are dissolving in disorientation. Medicine has led to inflated expectations, which the public eagerly swallow. Yet as those expectations become unlimited, they are unfillable; medicine will have to redefine its limits even as it extends its capacity’ ( 3). Paradoxically, it was the extraordinary successes of medical research and practice in the period after the World War II that laid the foundation for medicine's present state of uncertainty ( 4). At least in the richer, western countries, morbidity and mortality resulting from infectious disease declined and, at the same time, life expectancy increased dramatically. In this heady period, society assumed that doctors could do anything and that a long, disease-free life was its right; illness and death were no longer a natural part of things. Unfortunately, the diseases that took the place of the infectious killers, heart disease, stroke, psychiatric disease, cancer and the rest, proved to be much more intractable. It gradually became clear that they are all multifactorial, reflecting both environmental and genetic factors, together with the ill-understood pathophysiology of ageing. Few turned out to be preventable, and even fewer curable. Medicine became an increasingly high-technology patch-up service, with spiralling costs and enormous pressures on its manpower. As the century ends, no western society has worked out how to pay for medical care, and many of its health-delivery systems are in a state of disarray. At the same time as these changes in the pattern of illness and health care, there have been some remarkable developments in the basic medical sciences. The availability of the new tools of molecular and cell biology has changed the emphasis of medical research from the study of patients or their organs to the exploration of disease at the level of cells and molecules. In a relatively short time, we have gained previously undreamt of insights into molecular and cellular pathology, and there has been a dramatic change in the aspirations of the pharmaceutical industry, with the assumption that this new knowledge will provide opportunities for major therapeutic advances in the near future. Unfortunately, however, the clinical impact of this revolution in biomedical research has, so far, been relatively small. Similarly, while modern epidemiology promised so much with its demonstration of the relationship between cigarette smoking and lung cancer, much of what followed provided a plethora of potential risk factors for some of our present killers, but so many inconsistencies and uncertainties that much of current public health is based more on hope than reality. It is not surprising, therefore, that medical practice enters the new millennium in a state of uncertainty. As Roy Porter has reminded us, it has certainly led to inflated expectations, which both the public and its politicians have eagerly swallowed. But what we don't know, largely because of ignorance about the future applications of the revolution in the biomedical sciences, is whether Porter is also right to say that they are unfillable. In short, we have reached a halfway house; there is much we can do for most of the diseases that we encounter in practice, but at enormous expense, and our ability to prevent or radically cure them seems as far away as ever. How does haematology measure up when examined in the light of all these uncertainties? The last 50 years have seen an extraordinary increase in our knowledge of the pathophysiology of almost all the common blood diseases ( 7; 2). We can control or cure most of the deficiency disorders, have been reasonably successful in our management of some of those th