THE COST OF IGNORANCE I am frequently reminded of how very expensive knowledge and research are, but have you stopped to consider the cost of ignorance? The twentieth century, more than any other, has been characterized by scientific advance; there can be few who have not been touched for good or ill by science and its technological products. Huge amounts of money have been invested in science for deadly purposes and for humane, widely desirable ends. An expression we have grown accustomed to over the past decade is value for money. It now has several meanings and is even seen by some as a coded signal for political views of a particular hue. But it is a very important matter and it behoves all of us working in and through science to consider the effectiveness of what we do and its costs. Are we using our resources in an efficient way, are we achieving what we set out to do, and do we know what we want?

Medicine, like education, is about shaping outcomes. The doctor intervenes to prevent a particular condition, ameliorate its effects, or change a given state. All manner of approaches and methods are employed by doctors, nurses, therapists and other specialists to influence the lives of individuals. The bewildering array of variables which affect outcomes, and the many individuals who contribute their skills as needed, make it extremely difficult to measure the costs of disease and development in our children. To obtain accurate measures is not possible, but some important broad and useful comparisons can be made.

Lewis Thomas (The Lives of a Cell, 1974) suggests that three levels of technology can be distinguished in medicine. The first of these is really non- technology and relates to the supportive therapy and general care given to patients. It is directed at helping people to cope. It gives them hope, confidence, and a belief that they can exert some influence over their destinies. In the case of disabled children and their families, it is immensely important. This indis- pensable and highly valued part of medicine is also very costly and becoming more so all the time. The second level Thomas called halfway-technology. This will be seen by some as scientific medicine at its most splendid. It is the ‘hi-tech’ world of organ transplants and the like. Of course it is expensive and the demands for its expansion.appear insatiable. The third level is that which is based on an understanding of disease processes, their causes and course of action. It is from this approach that most of the great advances of modern medicine derive. There

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are many examples: antibiotics, some chemotherapy, the treatment of endo- crinological disorders with appropriate hormones, certain nutritional disorders and much promise from genetic engineering.

Each of these levels is needed, and medicine will continue to operate across them. The relative importance of particular conditions changes as new ways of containing, treating and preventing disease emerge. However, from the stand- point of cost-effectiveness, level three is the most efficient. Knowledge and the research from which it comes is therefore vital, and science, you might say, is too important to be left simply to the scientists. It is essential that we all, practitioners and patients alike, have some understanding of the role of science in our society and in medical care and treatment. Basic or pure research, as it is sometimes called, is not a luxury, it is not something to be done if there happens to be money left over from other things. It is vital, because this is how new knowledge is created and it is this which leads to a new understanding of both the disease condition and the human condition. Choices have to be made and priorities established, but this can only be done satisfactorily when we have an appreciation of the nature and function of research. Everyone is aware that research is expensive, but not many seem to be aware just how expensive ignorance is. Scientists must get this across to the public. We shall only be able to sustain the necessary research when the community as a whole has a better understanding of the scientific endeavour.

KEVIN CONNOLLY

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