What Would Our Forefathers Think?

The ACR celebrated the 75th anniversary of our organization at the annual meeting in Philadelphia this October. While an occasion to look forward, an anniversary inevitably stirs the urge to look back. The past elicits powerful emotions because it is known and fixed in time, with 75 candles blazing away in a mini-inferno, signaling the passage of years. In contrast, the future is unknown and uncertain. Optimism notwithstanding, the future can make us anxious.

As the lectures at the opening session dramatically illustrated, to paraphrase an old commercial for a product that most certainly needed a Risk Evaluation and Mitigation Strategy, we have come a long, long way, baby. The tales of rheumatologic disease during the Civil War were horrifying. Whether the joint afflictions were reactive arthritis or gonococcal arthritis, treatment by instillation of boiling chlorinated water was as likely to kill as to cure. The mortality during the Civil War was staggering, although I was surprised by the immense toll of “rheumatism.”

Civil War–era physician.

Great Leaps Forward for Rheumatology

Like most medical specialties during the last century, rheumatology has made spectacular progress. Certainly, since the founding of the ACR, our specialty has followed a steep upward trajectory, with continuous advances in the diagnosis and treatment of our major diseases, some of which have actually just about disappeared. Rheumatoid arthritis, osteoarthritis, gout, and lupus have all had major improvements in outcomes. Some of our most dreaded diseases are also being tamed. Indeed, as reported at one of the plenary sessions, anti–B cell treatment may provide a new alternative to treat vasculitis with fewer of the nasty effects of cyclophosphomide, the current standard.

Had one of the ACR founders attended the conclave in Philadelphia, he (I don’t think there was a she) would have been dazzled by the progress.

The history of an organization is like that of a person and springs from the complex interplay of genes and the environment. The genetics of the ACR are strong. Our founders were brave, resilient, and visionary physicians who banded together during the depth of the Depression to focus on the care of patients with arthritis. Even if the country was bankrupt and the treatment options paltry, these physicians saw a better future and charted a path than sustains us today. To our forebears in the ACR, thank you for a job well done. I wish you were here to blow out the candles with us.

While our heritage is strong, it will no doubt be challenged since we live in troubled times. Despite the remarkable and unquestioned advances in care resulting from research, both basic and clinical, our country has not yet decided how to pay for this care and how much it wants to pay. Do not believe the naysayers who doubt the existence of treatment advances. The question is not the size of the advances. It is about the size of price tag.

Different Struggles for Today’s Rheumatologist

With the ineffective care of the last century, costs were cheap. While a chicken or a few eggs could suffice for a co-payment (or even a payment) back then, with scientific advance, the cost of therapy for rheumatoid arthritis, for example, today ranges into the thousands and tens of thousands of dollars each year. To say the least, that’s a lot of chickens. Sadly, because of the current recession and the inadequacies and inequities of our healthcare system, many patients do not have access to the best therapy available or cannot afford it. Certainly, in the developing world, the cost of state-of-the-art care for inflammatory arthritis is out of sight for all but the wealthiest people. In some countries, a handful of rheumatologists struggle to treat patients with treatments from a half century ago.

Scientific meetings are probably not the place to address thorny and contentious issues of social and economic matters, especially when we get together with colleagues and old friends. When we drink a bit of bubbly, we do not want to have a reunion spoiled by an argument over the relative merits of the public option versus healthcare cooperatives. Meetings are times for reminiscence and sharing of pictures of children and grandchildren.

Nevertheless, politics is always in the air at the ACR meeting, especially since it immediately precedes the November election. In the United States, we are in the midst of a great struggle over the organization of our healthcare system. Unfortunately, the focus has been on partisanship, with the stakes measured in terms of the impact on the 2010 midterm elections rather than the health and well-being of millions of people.

Politicians and the press tend to pose issues in terms of the lives of people with names like Joe the Plumber or Harry and Louise. I like to think more numerically about public health issues and have to wonder how many QALYs (Quality-Adjusted Life-Years), DALYs (Disability-Adjusted Life-Years), or cumulative points on the Sharp score have resulted from the lack of universal coverage of patients with arthritis.

Embarrassment of Riches?

During the Philadelphia meeting, I went over to the exhibit area to talk to a colleague in industry. The exhibit area was booming with displays with whizzbang technology, enticing spreads of chocolate cake and pretzels, and coffee bars galore. In the old days, exhibits used to have bowls of medication samples. If there was ever a circumstance that called for a proton pump inhibitor, the combination of a mustard-soaked pretzel and a cappuccino is it. I would have gladly snatched a packet of Protonix if it were there and had I chosen to indulge.

In the exhibit hall, every so often, a great cheer of glee and excitement would erupt. The first time it happened I thought that the ban on giveaways had been lifted and the logo-emblazoned pens were on their way. Alas, the pens stayed in a warehouse somewhere and the shouting was about someone who had made a hole-in-one on an Astroturf miniature golf course. The course was part of a product display for a biologic, and I can also guess about the link between putting and a targeted therapy.

One of many paradoxes of modern medicine is the curious juxtaposition of commerce and science, with golf challenges and computer games attracting meeting attendees to learn about treatment advances. Since the founding of the ACR, the amount of money flowing in the system has grown gigantically. In future columns, I will discuss how to deal this flow (torrent?), and hopefully how to channel it to match the priorities of both patient and healthcare provider.

Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.